Nonaccidental Pediatric Trauma: Which Traditional Clues Predict Abuse?

OBJECTIVES: The objective of this study is to determine which of the child abuse clues quoted in the literature predict nonaccidental trauma (NAT): history incongruent with injuries found on examination or imaging, old injuries present, history of trauma denied by caregivers, multiple fractures present, changing history, fractures of varied duration, metaphyseal fracture, ear bruise, neck bruise, different history (second historian), and metaphyseal fracture. METHODS: This is a 4-year retrospective study of all suspected NAT cases referred to our medical center. In addition to the index visit, medical records were searched for visits before the index visit with patient historical or physical findings that might have suggested NAT but were not investigated. The association of diagnostic clues and the outcome were assessed by chi-square and logistic regression analysis. RESULTS: For 48 months, there were 109 cases of suspected NAT referred for evaluation (age range, 1 week to 15 years). After formal investigation by an abuse specialist, 79.3% of the cases were considered "likely abuse". Those historical or physical findings with a univariate association with a final conclusion of likely abuse included history incongruent with injuries, old injuries present, trauma history denied, changed history, and retinal hemorrhage. In multivariate logistic regression, only a history incongruent with injures remained an independent predictor of likely abuse (odds ratio, 8.65; 95% confidence interval, 1.74-43.07; P = 0.0151). After review of prior records, in only 2 of 109 cases (1.8%) was there a prior visit where NAT could have been suspected; however, history was thought to be congruent with the injury at the original visits. CONCLUSION: In this 4-year study of NAT, the clinical clue that best predicted likely abuse after expert investigation was a history that was incongruent with the injuries found on emergency department evaluation. The incidence of possible early recognition from a prior emergency department visit in this group was very low, <2% of cases.

Radiologists' Diagnostic Performance in Differentiation of Rickets and Classic Metaphyseal Lesions on Radiographs: A Multicenter Study.

BACKGROUND. Despite evidence supporting the specificity of classic metaphyseal lesions (CML) for the diagnosis of child abuse, some medicolegal practitioners claim that CML result from rickets rather than trauma. OBJECTIVE. The purpose of this study was to evaluate radiologists' diagnostic performance in differentiating rickets and CML on radiographs. METHODS. This retrospective seven-center study included children younger than 2 years who underwent knee radiography from January 2007 to December 2018 and who had either rickets (25-hydroxyvitamin D level < 20 ng/mL and abnormal knee radiographs) or knee CML and a diagnosis of child abuse from a child abuse pediatrician. Additional injuries were identified through medical record review. Radiographs were cropped and zoomed to present similar depictions of the knee. Eight radiologists independently interpreted radiographs for diagnoses of rickets or CML, rated confidence levels, and recorded associated radiographic signs. RESULTS. Seventy children (27 girls, 43 boys) had rickets; 77 children (37 girls, 40 boys) had CML. Children with CML were younger than those with rickets (mean, 3.7 vs 14.2 months, p < .001; 89.6% vs 5.7% younger than 6 months; 3.9% vs 65.7% older than 1 year). All children with CML had injuries in addition to the knee CML identified at physical examination or other imaging examinations. Radiologists had almost perfect agreement for moderate- or high-confidence interpretations of rickets (κ = 0.92) and CML (κ = 0.89). Across radiologists, estimated sensitivity, specificity, and accuracy for CML for moderate- or high-confidence interpretations were 95.1%, 97.0%, and 96.0%. Accuracy was not significantly different between pediatric and nonpediatric radiologists (p = .20) or between less experienced and more experienced radiologists (p = .57). Loss of metaphyseal zone of provisional calcification, cupping, fraying, and physeal widening were more common in rickets than CML, being detected in less than 4% of children with CML. Corner fracture, bucket-handle fracture, subphyseal lucency, deformed corner, metaphyseal irregularity, and subperiosteal new bone formation were more common in CML than rickets, being detected in less than 4% of children with rickets. CONCLUSION. Radiologists had high interobserver agreement and high diagnostic performance for differentiating rickets and CML. Recognition that CML mostly occur in children younger than 6 months and are unusual in children older than 1 year may assist interpretation. CLINICAL IMPACT. Rickets and CML have distinct radiographic signs, and radiologists can reliably differentiate these two entities.

Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status.

This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.

"Guboow"-child abuse or traditional medical treatment? a case report.

The examination of children suspected of being abused poses a great challenge for forensic pathologists. The risk of misjudgment is high and can have serious consequences for the child and the family. In unclear cases, an assessment should always be carried out on an interdisciplinary basis with the involvement of the relevant disciplines such as pediatrics, dermatology, or radiology. We present the case of a 2.5-year-old boy who was presented by his parents at the Pediatric Emergency Department of a Swiss University Hospital due to fever and weight loss. During the physical examination, conspicuous findings on the abdomen were present, and the responsible emergency physicians informed the child protective services. A clinical forensic examination occurred on behalf of the child protection services. The abdomen of the child showed several symmetrical scars. The initial questioning of the parents did not provide clear information about the origin of the injuries. Further professional questioning of the family by the child protective services concluded that the injuries were the result of a traditional medical treatment in Somalia, which occurred several weeks before.

Factors associated with physicians' assessment and management of child abuse and neglect: A mixed method study.

Physicians are a professional group that is highly likely to encounter abused or at-risk children. The aim of this study is to investigate physicians' experiences with abuse cases, their evaluations of abuse risk factors, and their attitudes toward becoming more educated on the subject. One-hundred-sixty-four family physicians at family health centers and public health centers completed a questionnaire, and a group of residents at a university training and research hospital were interviewed in a semi-structured format. One-fifth of the participants had managed a child abuse case at least once. Nearly half of the participants reported acting alone in diagnosing and managing abuse cases. Sixty-eight percent of these physicians stated they would like to receive training on this subject. Gender and having children did not make a difference as to the abuse-management experience of these medical professionals. Female participants placed more importance on risk factors related to "children with mental disabilities" and "alcohol and substance abuse in parents" than their male counterparts. Difficulties in diagnosis, concerns about handling the abuse cases, the impact of culture, various risk factors, the importance of teamwork and a holistic approach, the need for practical training, and the importance of primary prevention were themes that emerged from this survey. This study provides inferences as to which of the physician competencies should be targeted in undergraduate medical education.

Differential diagnosis between physical maltreatment and cupping practices in a suspected child abuse case.

Physical maltreatment is one of the most common forms of child abuse. Cutaneous injuries often raise the suspicion of child maltreatment. Nevertheless, among health professionals there is still uncertainty in the evaluation of such injuries. In the literature, there are few indications about the most important factors that allow the differentiation of physical abuse findings from signs/lesions that are caused by "folk medicine practices" with similar presentations. We report the case of two brothers who were brought to the Emergency Department of a pediatric hospital by their father because each of them showed one painful, circular and red-purple bruise on their back. Suspecting child abuse, the emergency physicians reported the case to a multidisciplinary unit (dedicated to child abuse). After a careful physical examination, psychological interviews, as well as the evaluation of their medical history, the operators pointed out that the lesions were the result of cupping practices (a form of folk medicine). This case highlights the need for a multidisciplinary approach and demonstrates the importance of a careful evaluation of the cultural background of the family.

Pediatric Major Head Injury: Not a Minor Problem.

Traumatic brain injury is a highly prevalent and devastating cause of morbidity and mortality in children. A rapid, stepwise approach to the traumatized child should proceed, addressing life-threatening problems first. Management focuses on preventing secondary injury from physiologic extremes such as hypoxemia, hypotension, prolonged hyperventilation, temperature extremes, and rapid changes in cerebral blood flow. Initial Glasgow Coma Score, hyperglycemia, and imaging are often prognostic of outcome. Surgically amenable lesions should be evacuated promptly. Reduction of intracranial pressure through hyperosmolar therapy, decompressive craniotomy, and seizure prophylaxis may be considered after stabilization. Nonaccidental trauma should be considered when evaluating pediatric trauma patients.

Protocolo de atención en salud integral de niñas y niños en situación de maltrato infantil / Comprehensive health care protocol for girls and boys in situations of child abuse

A partir de la premisa, que el maltrato infantil se está convirtiendo en un problema cada vez más serio a nivel nacional, situación que es avalada por la Organización Panamericana de la Salud (OPS) que considera que la violencia y sus diferentes manifestaciones son un problema que afectan a la salud y al desarrollo social y económico de amplios sectores de la población. Este protocolo considera que es importante que los proveedores de salud desarrollen habilidades y competencias que ayuden a detectar los casos de niños maltratados, así como conocer las mejores estrategias de intervención. El objetivo de este protocolo es proponer una herramienta que proporcione los elementos básicos a proveedores y proveedoras de salud para brindar atención de calidad en salud integral y realizar la notificación oportuna de los casos de maltrato infantil. Para ello han seleccionado un modelo basado en el triage del AIEPI (Atención Integral a las Enfermedades Prevalentes de la Infancia). Es una estrategia elaborada por la Organización Mundial de la Salud (OMS) y el Fondo de las Naciones Unidas para la Infancia (Unicef) presentada en 1996 como principal método para mejorar la salud en la niñez. La metodología del modelo se lleva a cabo por medio de tres componentes. El primero está dirigido a mejorar el desempeño del personal de salud para la prevención de enfermedades en la niñez y su tratamiento. El segundo se dirige a mejorar la organización y funcionamiento de los servicios de salud para que brinden atención de calidad apropiada; y el tercer componente está dirigido a mejorar las prácticas familiares y comunitarias de cuidado y atención de la niñez. Contiene un marco teórico, marco legal, así como una serie de anexos dirigidos a apoyar tanto el diagnóstico, como el seguimiento dado a las víctimas.

Bruising caused by traditional Chinese massage therapy (ba sha) complicating the assessment of a case of fatal child abuse.

Precise evaluation of bruises and patterned skin lesions in infants and children is an essential requirement in cases of potential abuse. Such injuries may be markers of more significant internal injuries and/or may be supportive of an assault rather than an accident. On occasion, however, unusual patterned skin lesions may be identified that have been inflicted as part of traditional therapeutic techniques. A five-year-old boy from a rural Chinese community is reported who died from ligature strangulation. In addition to bruises from abusive trauma he had a series of unusual patterned, often-paired, bruises over the anterior and posterior aspects of both shoulders, unrelated to the ligature mark. Upon further police inquiries it transpired that his grandmother and mother had been using traditional Chinese therapeutic massage or "ba sha" to treat an episode of vomiting. The term means "to pull out fever" and involves firm pinching of the skin between the thumb and index finger, often on the neck, chest or back. An awareness of the potential manifestations of traditional therapies is important in contemporary forensic practice so that injuries caused by these treatments are not confused with non-therapeutic inflicted injury.

Dissociation and symptoms of culture-bound syndromes in North America: a preliminary study.

The aim of this study was to determine whether classical culture-bound syndromes occur among psychiatric inpatients with dissociative disorders in North America. The Dissociative Trance Disorder Interview Schedule, the Dissociative Experiences Scale, and the Dissociative Disorders Interview Schedule were administered to 100 predominantly Caucasian, American, English-speaking trauma program inpatients at a hospital in the United States. The participants reported high rates of childhood physical and/or sexual abuse (87%), dissociative disorders (73%), and membership in the dissociative taxon (78%). They also reported a wide range of possession experiences and exorcism rituals, as well as the classical culture-bound syndromes of latah, bebainan, amok, and pibloktoq. Our data are consistent with the view that possession and classical culture-bound syndromes are predominantly dissociative in nature and not really culture-bound from the perspective of Caucasian, English-speaking America.

Copper deficiency presenting as metabolic bone disease in extremely low birth weight, short-gut infants.

Copper deficiency can cause bone lesions in infants, which might be confused with child abuse. Two extremely low birth weight preterm infants had complicated medical courses requiring prolonged parenteral nutrition for short-gut syndrome, which led to the development of cholestasis. Both had spent their entire lives in the hospital. They had been on prolonged ventilator support for chronic lung disease. They developed signs of copper deficiency between 5 and 6 months of age, initially raising child abuse concerns. Musculoskeletal discomfort led to the recognition of radiographic findings of metabolic bone disease. Included were osteoporosis, metaphyseal changes, and physeal disruptions. Copper levels were low; both low copper parenteral nutrition and gut losses from refeeding diarrhea likely contributed to their deficiency. Therapeutic supplementation with copper corrected their deficits and clinical and radiologic findings. The information from these cases, in particular, their radiologic findings, indicate the need to monitor copper status in at-risk premature infants. These findings may aid prevention and earlier recognition of copper deficiency. Their specific radiologic and clinical findings should aid differentiation of such children from abused infants.

Child dental neglect: is it a neglected area in the UK?

This commentary focuses on the condition of dental neglect (DN) in children in the UK. It is divided into three sections: the first section defines DN in children and its consequences, the second section discusses who may be responsible for dental diseases in children as a result of neglect and the third section proposes a holistic approach to address DN in children in the UK.

Everyone's business: developing an integrated model of care to respond to child abuse in a pediatric hospital setting.

In pediatric hospitals, social work plays a central role in the prevention, identification, and management of child abuse. Children who are suspected of having been abused or neglected require an evaluation of their psychosocial situation. As an integral member of the health care team, the social worker is well placed to undertake comprehensive psychosocial assessments including information on the child's development, parental capacity, family, and community supports. Current practice approaches have seen a shift away from a narrow, "expert" approach to child protection. This article describes the development of an integrated model of social work service delivery to better respond to vulnerable and at-risk children in a pediatric hospital setting. Developing a new model of service required strategic planning, consultation, and endorsement from senior hospital management. The new model aimed to ensure a high quality, responsive social work service to children at risk of physical abuse, neglect, or cumulative harm. The change necessitated understanding of current research evidence, development of best practice guidelines, and effective communication with staff and external stakeholders. Policy development, implementation of practice guidelines, staff training, data collection, and service evaluation are described. The role of social work management and leadership were central in creating change. Visionary leadership is widely regarded as key to successful organizational change. The management approach included consultation with staff, building commitment to the need for change, addressing staff concerns, and providing a vision of enhanced client outcomes as a result of the change process. This article provides a candid overview of challenges and barriers to change. Change strategies described are easily transferable to other social work settings.

Assessing the concordance of health and child protection data for 'maltreated' and 'unintentionally injured' children.

OBJECTIVES: To quantify the concordance of hospital child maltreatment data with child protection service (CPS) records, and identify factors associated with linkage. METHODS: Multivariable logistic regression analysis was conducted following retrospective medical record review and database linkage of 884 child records from 20 hospitals and the CPS in Queensland, Australia. RESULTS: Nearly all children with hospital assigned maltreatment codes (93.1%) had a CPS record. Of these, 85.1% had a recent notification. 29% of the linked maltreatment group (n=113) were not known to the CPS prior to the hospital presentation. Almost one third of children with unintentional injury hospital codes were known to the CPS. Just over 24% of the linked unintentional injury group (n=34) were not known to the CPS prior to the hospital presentation but became known during or after discharge from hospital. These estimates are higher than the 2006/2007 annual rate of 2.39% of children being notified to the CPS. Rural children were more likely to link to the CPS, and children were over three times more likely to link if the index injury documentation included additional diagnoses or factors affecting their health. CONCLUSIONS: The system for referring maltreatment cases to the CPS is generally efficient, although up to 1 in 15 children had codes for maltreatment but could not be linked to CPS data. The high proportion of children with unintentional injury codes who linked to CPS suggests that clinicians and hospital-based child protection staff should be supported by further education and training to ensure children at risk are being detected by the child protection system.

Spa-drain entrapment complicated by suspicions of nonaccidental trauma and epilepsy onset.

We present here the case of an adolescent female near-drowning victim who was reportedly discovered submerged and unconscious by family members in a whirlpool spa. Physical examination revealed extensive posterior soft tissue bruising, which raised the suspicion of nonaccidental trauma. Detailed forensic evaluation of the injuries and the scene proved that the soft tissue findings represented an unusual manifestation of whirlpool-spa suction-vent injury. Medical evaluation indicated that epilepsy onset might have contributed to the near-drowning, although forensic evaluation of this possibility was less convincing. In this article we review these rare but important injuries, which have the potential to be confused with child abuse, and detail the atypical presentation and clinically presumed etiologic event in our case.