The Prevalence of Bruising Among Infants in Pediatric Emergency Departments.

STUDY OBJECTIVE: Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. METHODS: We conducted a prospective, observational, multicenter study of infants aged 12 months or younger presenting to pediatric EDs. Structured sampling was used. Pediatric emergency medicine clinicians performed complete skin examinations to screen for bruising. Study investigators documented skin findings, date of visit, patient's age, chief complaint, and abuse evaluation. The primary outcome was prevalence of bruising. Secondary outcomes were prevalence of bruising based on chief complaint and frequency of abuse evaluation. Point estimates of bruise prevalence and differences in bruise prevalence between patient subgroups were calculated with 95% confidence intervals (CIs). RESULTS: Bruising was identified in 88 of 2,488 infants (3.5%; 95% CI 2.9% to 4.4%). Rates of bruising for infants 5 months and younger and older than 5 months were 1.3% and 6.4%, respectively (difference 5.1%; 95% CI 3.6% to 6.8%). For infants 5 months and younger, 83% of bruising was associated with a trauma chief complaint and only 0.2% of infants presenting with a medical chief complaint had bruising. Pediatric emergency medicine clinicians obtained abuse evaluations on 23% of infants with bruising, and that rate increased to 50% for infants 5 months and younger. CONCLUSION: Bruising prevalence in children 12 months and younger who were evaluated in pediatric EDs was low, increased within age strata, and was most often associated with a trauma chief complaint. Most bruised infants did not undergo an abuse evaluation.

Assessment of injury potential in pediatric bed fall experiments using an anthropomorphic test device.

Falls from beds and other furniture are common scenarios provided to conceal child abuse but are also common occurrences in young children. A better understanding of injury potential in short-distance falls could aid clinicians in distinguishing abusive from accidental injuries. Therefore, this study investigated biomechanical outcomes related to injury potential in falls from beds and other horizontal surfaces using an anthropomorphic test device representing a 12-month-old child. The potential for head, neck, and extremity injuries and differences due to varying impact surfaces were examined. Linoleum over concrete was associated with the greatest potential for head and neck injury compared to other evaluated surfaces (linoleum over wood, carpet, wood, playground foam). The potential for severe head and extremity injuries was low for most evaluated surfaces. However, results suggest that concussion and humerus fracture may be possible in these falls. More serious head injuries may be possible particularly for falls onto linoleum over concrete. Neck injury potential in pediatric falls should be studied further as limitations in ATD biofidelity and neck injury thresholds based solely on sagittal plane motion reduce accuracy in pediatric neck injury assessment. In future studies, limitations in ATD biofidelity and pediatric injury thresholds should be addressed to improve accuracy in injury potential assessments for pediatric short-distance falls. Additionally, varying initial conditions or pre-fall positioning should be examined for their influence on injury potential.

Pediatric short-distance household falls: biomechanics and associated injury severity.

OBJECTIVES: Short-distance household falls are a common occurrence in young children, but are also a common false history given by caretakers to conceal abusive trauma. The purpose of this study was to determine the severity of injuries that result from accidental short-distance household falls in children, and to investigate the association of fall environment and biomechanical measures with injury outcomes. METHODS: Children aged 0-4 years who presented to the Emergency Department with a history of a short furniture fall were included in the study. Detailed case-based biomechanical assessments were performed using data collected through medical records, interviews, and fall scene investigations. Injuries were rated using the Abbreviated Injury Scale (AIS). Each case was reviewed by a child abuse expert; cases with a vague or inconsistent history and cases being actively investigated for child abuse were excluded. RESULTS: 79 subjects were enrolled in the study; 15 had no injuries, 45 had minor (AIS 1) injuries, 17 had moderate (AIS 2) injuries, and 2 had serious (AIS 3) injuries. No subjects had injuries classified as AIS 4 or higher, and there were no fatalities. Children with moderate or serious injuries resulting from a short-distance household fall tended to have fallen from greater heights, have greater impact velocities, and have a lower body mass index than those with minor or no injuries. CONCLUSION: Children aged 0-4 years involved in a short-distance household fall did not sustain severe or life-threatening injuries, and no children in this study had moderate or serious injuries to multiple body regions. Biomechanical measures were found to be associated with injury severity outcomes in short-distance household falls. Knowledge of relationships between biomechanical measures and injury outcomes can aid clinicians when assessing whether a child's injuries were the result of a short-distance fall or some other cause.

Does valsalva retinopathy occur in infants? An initial investigation in infants with vomiting caused by pyloric stenosis.

OBJECTIVE: Retinal hemorrhages (RHs) are 1 manifestation of child abuse, and although they often are considered to be diagnostic of abuse in a young child, there are other potential causes. RHs have been described in association with valsalva maneuver, such as forceful vomiting or coughing. Our aim was to describe the incidence of RH in infants with vomiting caused by pyloric stenosis. METHODS: A prospective, descriptive study was conducted of infants who underwent pyloromyotomy for hypertrophic pyloric stenosis (HPS). Dilated retinal examinations were performed, and the findings were documented. RESULTS: A total of 100 infants with HPS were evaluated. Eighty-four infants were male, 92 were white, and 21 had a family history of pyloric stenosis. Thirty-seven examinations were performed in the operating room. Eighteen examinations were confirmed by a second investigator, and 3 children had dilated eye examinations documented independently by a pediatric ophthalmologist. No RHs were identified (0 of 100; 95% confidence interval: 0%-3%). One patient had facial petechiae, and 2 had subconjunctival hemorrhage. Electrolyte levels were abnormal in 63 patients. In 89 cases, the emesis was described as projectile. Patients varied in the number of episodes of emesis, with 30% of patients having >100 episodes of emesis before diagnosis. One patient had a respiratory arrest associated with vomiting in the emergency department and required bag-valve mask ventilation. CONCLUSIONS: No RHs were identified in 100 infants with vomiting caused by HPS. These results suggest that RHs do not result from forceful vomiting in infants.