Suboptimal care was frequent in severe child physical abuse cases and was mainly related to delayed diagnoses and ineffective secondary prevention.

AIM: Our aim was to assess suboptimal care before a diagnosis of severe child physical abuse in western France. METHODS: A confidential inquiry was carried out, based on children under 6 years of age who were hospitalised in the Nantes regional university hospital from 2016 to 2018. Two researchers retrospectively reviewed the medical records of all the children who were reported to the authorities for suspected severe child physical abuse. Two experts determined the optimality of care and identified the main categories of suboptimal care. RESULTS: The median age of the 94 children included in the study was 8 months. A fifth of them had intra-cranial injuries and a quarter had fractures. One child died and a third had severe sequelae at hospital discharge. Included children frequently (37%) received suboptimal care before the diagnosis of severe CPA and this fell into two categories: delayed diagnosis was experienced by 17% and ineffective secondary prevention by 22%. CONCLUSION: Suboptimal care for severe child physical abuse was frequent and fell into two categories: delayed diagnosis and ineffective secondary prevention. These results can help us to design corrective actions.

Maternal, prenatal and postnatal risk factors for early child physical abuse: a French nationwide cohort study.

Background: Identifying risk factors for early child physical abuse (CPA) is crucial for understanding its mechanisms and defining effective preventive interventions. We aimed to identify maternal, prenatal and postnatal factors associated with early CPA. Methods: This cohort study was based on comprehensive data from the Mother-Child EPI-MERES nationwide register and included all infants born alive in France between 2010 and 2019. Factors associated with early CPA (before age 1) were identified with a multilevel Cox regression model with random intercepts at the regional level. Findings: Among the 6,897,384 included infants, 2994 (40/100,000) had a diagnosis of early CPA, at a median age of 4 months. Independent factors most strongly associated with early CPA were maternal low financial resources (adjusted hazard ratio [aHR] 1.91; 95% confidence interval [95% CI] 1.67-2.18), maternal age <20 years versus 35-40 years (aHR 7.06; 95% CI 6.00-8.31), maternal alcohol use disorder (aHR 1.85; 95% CI 1.48-2.31), opioid use disorder (aHR 1.90; 95% CI 1.41-2.56), intimate partner violence (aHR 3.33; 95% CI 2.76-4.01), diagnosis of a chronic mental disorder (aHR 1.50; 95% CI 1.14-1.97) or somatic disorder (aHR 1.55; 95% CI 1.32-1.83), hospitalisation for a mental disorder (aHR 1.88; 95% CI 1.49-2.36), very preterm birth (aHR 2.15; 95% CI 1.68-2.75), and diagnosis of a chronic severe neurocognitive disorder in the infant (aHR 14.37; 95% CI 11.85-17.44). Interpretation: Independent risk factors of early CPA identified at the national level in France may help in understanding CPA mechanisms and developing effective prevention programs including risk-stratification tools to optimise the allocation of parenting interventions to parents who could most benefit from them. Funding: Ile-de-France regional council, L'Oréal-UNESCO For Women In Science France Young Talent Award, French National Observatory for Child Protection [ONPE], French Association of Ambulatory Paediatrics [AFPA], HUGO university hospitals network, Mustela Foundation and Sauver la Vie prizes.

Abusive Head Trauma in Infants During the COVID-19 Pandemic in the Paris Metropolitan Area.

Importance: The COVID-19 pandemic and the containment and mitigation measures taken were feared to be associated with increased child abuse. Objective: To investigate the trend of abusive head trauma (AHT) incidence and severity in infants during the COVID-19 pandemic. Design, Setting, and Participants: In a time-series analysis of a longitudinal, population-based, cohort study, all consecutive cases of AHT in infants younger than 12 months old referred between January 2017 and December 2021 to Necker Hospital for Sick Children, the single regional pediatric neurosurgery center for the Paris metropolitan area, were included. AHT was defined as 1 or more subdural hemorrhage and a positive multidisciplinary evaluation after a social, clinical, biological, and radiological workup. Data were analyzed from January to March 2022. Main Outcomes and Measures: The primary outcome was the monthly incidence of AHT, which was analyzed using Poisson regression modeling. Secondary outcomes included mortality and severe morbidity and were studied with logistic and linear regressions. The monthly incidence of neurosurgical interventions for hydrocephalus was used as a control series. Results: Among the 99 included infants with AHT (median [IQR] age, 4 [3-6] months; 64 boys [65%]), 86 of 99 (87%) had bridging vein thrombosis, 74 of 99 (75%) had retinal hemorrhages, 23 of 72 (32%) had fractures, 26 of 99 (26%) had status epilepticus, 20 of 99 (20%) had skin injuries, 53 of 99 (54%) underwent neurosurgical interventions, and 13 of 99 (13%) died. Compared with the prepandemic period (2017-2019), AHT incidence was stable in 2020 (adjusted incidence rate ratio, 1.02; 95% CI, 0.59-1.77) and then significantly increased in 2021 (adjusted incidence rate ratio, 1.92; 95% CI, 1.23-2.99). The severity of AHT worsened in 2021 in terms of mortality (odds ratio 9.39; 95% CI, 1.88-47.00). Other secondary outcomes and the control series were not significantly modified. Conclusions and Relevance: In this cohort study, a marked increase in AHT incidence and severity occurred during the COVID-19 pandemic in the Paris metropolitan area. These results suggest the need for clinical awareness and preventive actions.

Add-on bone scintigraphy after negative radiological skeletal survey for the diagnosis of skeletal injury in children suspected of physical abuse: a systematic review and meta-analysis.

OBJECTIVES: To systematically assess the extent to which bone scintigraphy (BS) could improve the detection rate of skeletal injury in children suspected of physical abuse with an initial negative radiological skeletal survey (RSS). STUDY DESIGN: We searched MEDLINE and Web of Science for series of ≥20 children suspected of physical abuse who underwent RSS and add-on BS. We assessed the risk of bias and the heterogeneity and performed random-effects meta-analyses. RESULTS: After screening 1140 unique search results, we reviewed 51 full-text articles, and included 7 studies (783 children, mostly ≤3 years old). All studies were of either high or unclear risk of bias. Substantial heterogeneity was observed in meta-analyses. The summary detection rate of skeletal injury with RSS alone was 52% (95% CI 37 to 68). The summary absolute increase in detection rate with add-on BS was 10 percentage points (95% CI 6 to 15); the summary relative detection rate was 1.19 (95% CI 1.13 to 1.25); the summary number of children with a negative RSS who needed to undergo a BS to detect one additional child with skeletal injury (number needed to test) was 3 (95% CI 2 to 7). CONCLUSIONS: From the available evidence, add-on BS in young children suspected of physical abuse with a negative RSS might allow for a clinically significant improvement of the detection rate of children with skeletal injury, for a limited number of BS procedures required. The quality of the reviewed evidence was low, pointing to the need for high-quality studies in this field.

Variations in Guidelines for Diagnosis of Child Physical Abuse in High-Income Countries: A Systematic Review.

Importance: The highly variable practices observed regarding the early detection and diagnostic workup of suspected child physical abuse contribute to suboptimal care and could be partially related to discrepancies in clinical guidelines. Objective: To systematically evaluate the completeness, clarity, and consistency of guidelines for child physical abuse in high-income countries. Evidence Review: For this systematic review, national or regional guidelines that were disseminated from 2010 to 2020 related to the early detection and diagnostic workup of child physical abuse in infants aged 2 years or younger by academic societies or health agencies in high-income countries were retrieved. The definitions of sentinel injuries and the recommended diagnostic workup (imaging and laboratory tests) for child physical abuse were compared. Data were analyzed from July 2020 to February 2021. Findings: Within the 20 included guidelines issued in 15 countries, 168 of 408 expected statements (41%) were missing and 10 statements (4%) were unclear. Among 16 guidelines characterizing sentinel injuries, all of them included skin injuries, such as bruises, hematoma, or burns, but only 8 guidelines (50%) included intraoral injuries and fractures. All 20 guidelines agreed on the indication for radiological skeletal survey, head computed tomography, and head magnetic resonance imaging but differed for those of bone scintigraphy, follow-up skeletal survey, spinal magnetic resonance imaging, cranial ultrasonography, chest computed tomography, and abdominal ultrasonography and computed tomography. Additionally, 16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. Conclusions and Relevance: These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues. These results may help identify priorities for well-designed original diagnostic accuracy studies, systematic reviews, or an international consensus process to produce clear and standardized guidelines to optimize practices and infant outcomes.

Bone Scintigraphy After a Negative Radiological Skeletal Survey Improves the Detection Rate of Inflicted Skeletal Injury in Children.

Background: Timely diagnosis of child physical abuse is of paramount importance. The added value of bone scintigraphy (BS) after a negative radiological skeletal survey (RSS) in children with suspected physical abuse has never been evaluated. Objective: The objective of this study was to assess the extent to which BS could improve the detection rate of skeletal injury in children with suspected physical abuse with an initial negative RSS. Methods: We used discharge codes to retrospectively identify children evaluated for suspected physical abuse in a university hospital (Nantes, France). We included all consecutive children younger than 3 years old who underwent both RSS and BS, with an interval of ≤96 h between tests, from 2013 to 2019. BS and RSS results were interpreted independently during the study period. We specifically analyzed BS results for children with a negative RSS to assess the value of BS as an add-on test. Results: Among the 268 children ≤3 years old with suspected physical abuse who underwent RSS, 140 (52%) also underwent BS within 96 h and were included in the analysis. The median age was 6 months old (interquartile range: 3-8). The detection rate of ≥1 skeletal injury with RSS alone was 49% (n = 69/140, 95% CI: 41-58%) vs. 58% (n = 81/140, 50-66%) with RSS followed by add-on BS, for an absolute increase in the detection rate of 9% points (95% CI: 4-14%). The number of children with a negative RSS who would need to undergo BS to detect one additional child with ≥1 skeletal injury was 6 (95% CI: 4-11). Conclusion: In young children with suspected physical abuse with a negative RSS, add-on BS would allow for a clinically significant improvement in the detection rate of skeletal injuries for a limited number of BS procedures required. Prospective multicenter studies are needed to confirm these findings.