Financing pediatric hospital child abuse teams in 2015: National survey results.

BACKGROUND: Data available on the economics of medical child protection teams stems from prior surveys delivered in 2008 and 2012. OBJECTIVE: The objective was to describe the current financing strategies of medical child maltreatment groups for benchmarking purposes. Additionally, we aimed to quantify often difficult to measure child abuse services that provide value to pediatric hospitals. PARTICIPANTS AND SETTING: In 2017, a 115-item survey was distributed to 230 pediatric hospitals inquiring about child abuse services for the 2015 calendar year. METHODS: The financial topics including budget, revenue, reimbursement, expenses, research, education, and community partnership were analyzed using descriptive statistics. Previous data from similar surveys deployed in 2008 and 2012 were used when applicable to formulate trends. RESULTS: One hundred and thirteen children's hospitals responded comprising a response rate of 49 %. One hundred and four hospitals provided child abuse services at some level. Sixty-two programs (26 %) responded to items about budget. Overall, average team operating budgets increased from $1.15 million in 2008 to $1.4 million in 2015. Few clinical services rendered received full reimbursement. Valuable non-clinical services were poorly reimbursed. An average of 5.45 funding sources were used to supplement remunerations. CONCLUSION: Child maltreatment teams within pediatric hospitals provide services that are largely unfunded as they are not currently recognized by healthcare payment models. These specialists perform a variety of clinical and non-clinical responsibilities that are critical to the care of this population while relying on a variety of funding sources to support their efforts.

Are classic metaphyseal lesions pathognomonic for child abuse? Two cases of motor vehicle collision-related extremity CML and a review of the literature.

Long bone fractures at the infant growth plate, known as classic metaphyseal lesions (CMLs), raise a strong suspicion for abusive injury. CMLs persist as a hallmark for inflicted injury although a handful of documented cases of CMLs created by other, non-abusive mechanisms within various healthcare settings are scattered throughout the past few decades of medical literature. The forces required to sustain a CML are typically defined as a combination of tensile, compressive, or rotational energy applied to the metaphyseal regions of an infant's long bones. Recently, two separate child protection teams each encountered a case of CML discovered after reported motor vehicle collisions (MVC). This provoked a critical appraisal of the medical literature to inform clinical practice regarding MVCs as a potential mechanism for this fracture type and to remind clinicians that there is no single injury pathognomonic for abuse.

Nasal erosion as an uncommon sign of child abuse.

While various forms of facial trauma, bruising, burns, and fractures are frequently seen in cases of child abuse, purposeful nasal erosion has rarely been identified as a form of abusive injury. Progressive destruction of nasal tissue in children provokes a wide differential diagnosis crossing multiple subspecialties: infectious, primary immunodeficiencies, inflammatory conditions, malignancy, and genetic disorders. Progressive nasal erosion also can be a manifestation of child abuse. The proposed mechanism is repetitive mechanical denudation of the soft tissue and cartilage resulting in chronic inflammation, bleeding, and ultimately destruction of the insulted tissue. We report 6 cases of child abuse manifesting as overt nasal destruction.

Performance of computed tomography of the head to evaluate for skull fractures in infants with suspected non-accidental trauma.

BACKGROUND: Young children with suspected abusive head trauma often receive skull radiographs to evaluate for fractures as well as computed tomography (CT) of the head to assess for intracranial injury. Using a CT as the primary modality to evaluate both fracture and intracranial injury could reduce exposure to radiation without sacrificing performance. OBJECTIVE: To evaluate the sensitivity of CT head with (3-D) reconstruction compared to skull radiographs to identify skull fractures in children with suspected abusive head trauma. MATERIALS AND METHODS: This was a retrospective (2013-2014) cross-sectional study of infants evaluated for abusive head trauma via both skull radiographs and CT with 3-D reconstruction. The reference standard was skull radiography. All studies were read by pediatric radiologists and neuroradiologists, with ten percent read by a second radiologist to evaluate for interobserver reliability. RESULTS: One hundred seventy-seven children (47% female; mean/median age: 5 months) were included. Sixty-two (35%) had skull fractures by radiography. CT with 3-D reconstruction was 97% sensitive (95% confidence interval [CI]: 89-100%) and 94% specific (CI: 87-97%) for skull fracture. There was no significant difference between plain radiographs and 3-D CT scan results (P-value = 0.18). Kappa was 1 (P-value <0.001) between radiologist readings of CTs and 0.77 (P = 0.001) for skull radiographs. CONCLUSION: CT with 3-D reconstruction is equivalent to skull radiographs in identifying skull fractures. When a head CT is indicated, skull radiographs add little diagnostic value.