The monthly incidence of abusive head trauma, inflicted skeletal trauma, and unexplained skin lesion in children in six French university hospitals during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic was a stressful period. Lockdowns may have added to parental difficulty leading to an increase in violence. This study aimed to compare the monthly incidence of high suspicion of child physical abuse before and during the COVID-19 pandemic. MATERIAL: We have retrospectively reviewed imaging examinations of children having a skeletal X-ray examination in six university hospitals with high suspicion of abusive head traumatism (AHT), inflicted skeletal trauma (IST) and unexplained skin lesions (USL) between March 2020 and June 2021 and compared with the similar period from 2018 to 2019. The monthly incidence of the different physical maltreatment was analyzed using a QuasiPoisson regression model. RESULTS: We included 178 children (n = 127 boys, 71.3 %), 110 during the pandemic period, median age 5 months. AHT was diagnosed in 91 children, 55 had inflicted skeletal trauma (IST) and 46 had unexplained skin lesions (USL). Among the 91 patients with AHT, 86 had a subdural hematoma (95.6 %) and 40 had bridging veins thrombosis (44 %). The ophthalmological examination performed on 89 children (97.9 %) revealed retinal hemorrhages in 57 children (89.8 %). The incidence of AHT doubled during the months of COVID-19 lockdowns (rate ratio = 2; 95 % CI [1.1; 3.6], p = 0.03). No difference in monthly incidence was observed for IST and USL groups. CONCLUSION: A significant increase in AHT was observed during the months with lockdowns and curfews during the COVID-19 pandemic. This highlights the need for developing a national strategy to prevent physical abuse in children in this context.

Emergency Department Child Abuse Evaluations During COVID-19: A Multicenter Study.

BACKGROUND AND OBJECTIVE: The reported impacts of the COVID-19 pandemic on child maltreatment in the United States have been mixed. Encounter trends for child physical abuse within pediatric emergency departments may provide insights. Thus, this study sought to determine the change in the rate of emergency department encounters related to child physical abuse. METHODS: A retrospective study within the Pediatric Emergency Care Applied Research Network Registry. Encounters related to child physical abuse were identified by 3 methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or age-restricted skeletal survey completion. The primary outcomes were encounter rates per day and clinical severity before (January 2018-March 2020) and during the COVID-19 pandemic (April 2020-March 2021). Multivariable Poisson regression models were fit to estimate rate ratios with marginal estimation methods. RESULTS: Encounter rates decreased significantly during the pandemic for 2 of 3 identification methods. In fully adjusted models, encounter rates were reduced by 19% in the diagnosis-code cohort (adjusted rate ratio: 0.81 [99% confidence interval: 0.75-0.88], P <.001), with the greatest reduction among preschool and school-aged children. Encounter rates decreased 10% in the injury cohort (adjusted rate ratio: 0.90 [confidence interval: 0.82-0.98], P = .002). For all 3 methods, rates for lower-severity encounters were significantly reduced whereas higher-severity encounters were not. CONCLUSIONS: Encounter rates for child physical abuse were reduced or unchanged. Reductions were greatest for lower-severity encounters and preschool and school-aged children. This pattern calls for critical assessment to clarify whether pandemic changes led to true reductions versus decreased recognition of child physical abuse.

Incidence of child abuse with subdural hemorrhage during the first year of the COVID-19 pandemic: a nationwide study in France.

The global COVID-19 pandemic prompted governments to impose unprecedented sanitary measures, such as social distancing, curfews, and lockdowns. In France and other countries, the first COVID-19 lockdown raised concerns about an increased risk of child abuse. Abusive head trauma (AHT) is one of the most serious forms of child abuse in children aged 0-24 months and constitutes the leading cause of death in children under 2 years of age. Subdural hemorrhage (SDH) is present in 89% of cases of AHT and constitutes one of the most specific, objective clinical presentations in the diagnosis of child abuse. In a French nationwide study, we sought to evaluate the potential impact of the first year of the COVID-19 pandemic on the incidence of hospital admissions for child abuse with SDH, relative to the two previous years. We conducted a nationwide, retrospective study of data in the French national hospital discharge summary database by applying the International Classification of Diseases (10th Revision) codes for SDH and for child abuse. After including children aged up to 24 months with a diagnosis of child abuse and/or SDH following hospital admission anywhere in France between January 1, 2018, and December 31, 2020, we compared the incidence of child abuse, the incidence of SDH + child abuse, and the demographic data for 2020 with the corresponding values for 2018 and 2019. There were no significant differences in the number of hospital admissions due to child abuse or SDH + child abuse between 2020 and the 2018/2019 control years. The incidence of SDH + child abuse was higher among boys than among girls. There were significantly fewer hospital admissions in May 2020 (p = 0.01) and significantly more in December 2020 (p = 0.03), relative to the same months in the two preceding years. There was a nonsignificant trend toward a lower incidence of hospital admission for child abuse in 2020, relative to 2019 (decrease: 6.4%) and 2018 (decrease: 7.6%). CONCLUSION: When considering children under the age of 24 months in France, the incidence of hospital admission for SDH in the context of child abuse was not significantly higher in 2020 than in the two previous years. WHAT IS KNOWN: • The impact of COVID-19 lockdown on child abuse and more specifically on subdural hemorrhage remains unknown. WHAT IS NEW: • There was no increase in hospitalizations for child abuse and AHT. • We found that boys are more often victims of child abuse and subdural hemorrhage among children aged less than 12 months.

Evidence-Based Screening to Optimize the Yield of Positive Ophthalmologic Examinations in Children Evaluated for Suspected Child Abuse.

PURPOSE: To determine nonocular findings associated with significant retinal hemorrhage on dilated fundus examination in cases of suspected child abuse. METHODS: This was a retrospective chart review from May 2014 to August 2021 at a level-1 trauma center. Two hundred seventy-four patients met the following inclusion criteria: (1) children 36 months and younger; (2) concern for child abuse; and (3) had an ophthalmology consultation. Through univariate and multivariate logistic regression, the study produced a screening algorithm for ophthalmic work-up in child abuse. RESULTS: One or more abnormal neuroimaging findings had a statistically significant association with retinal hemorrhages and produced the strongest association with a univariate odds ratio of 170 (confidence interval: 10.245 to > 999.999). The multivariate model (P < .0001 with a c-statistic of 0.980) proposes using the following variables for predicting retinal hemorrhage on examination: abnormal neuroimaging, Glasgow Coma Scale score less than 15, altered mental status on examination, seizure activity, vomiting, bruising, scalp hematoma/swelling, and skull fractures. CONCLUSIONS: This study elucidates clinical and imaging factors that correlate to retinal findings, validating previously studied variables and introducing new variables to be considered. The authors propose an evidence-based screening algorithm to increase the yield of positive dilated examinations and decrease the burden of potentially unnecessary child abuse ophthalmologic examinations. [J Pediatr Ophthalmol Strabismus. 2022;59(5):310-319.].

Early recognition of child abuse through screening indicators at the emergency department: experience of a tertiary urban pediatric hospital.

BACKGROUND: Emergency Departments play a pivotal role in detecting cases of child abuse. Despite the efforts made in the past decades on the need for a screening method for the early detection of abuse victims, a unique instrument shared by the international scientific community has not been made. These instruments should be able to help recognizing whether it is necessary to further investigate the child's condition. The aim of the study is to illustrate the screening indicators in use since 2010 in the Emergency Department of the Bambino Gesù Children's Hospital to early recognise the victims of abuse and the modifying process of the screening tool undertaken over the years. METHODS: We retrospectively analyzed the process that led to the editing of the indicators of child abuse in use nowadays at the Bambino Gesù Children's Hospital. We codified three clinical pathways to apply in case of suspected abuse. Furthermore, we investigated the medical records of screening-positive accesses in the Paediatric Emergency Department of the Bambino Gesù Children's Hospital from January 2008 to October 2020. RESULTS: An estimation of positive screening, regarding the type of abuse suspected, and the number of accessed in ED was made, resulting in a cohort of 956 patients. In 2010 we created a list of 14 items grouped in three clusters: anamnestic declarations or incongruences, carelessness/neglect and evident lesions at physical examination. Positivity to one of the items allows the actuation of the investigating protocol named as clinical pathway.In 2013, after three years of experience, the criteria were edited to increase specificity. The application of screening led to a median number of 82 suspected cases/year from 2013 to 2020. CONCLUSION: A screening tool is essential and productive for the early recognition of victims of abuse. An in-deep analysis of suspected cases through a standardized method, such as the clinical pathway, allowed reaching the diagnosis in a more accurate and precise manner.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown.

Rate and severity of radiological features of physical abuse in children during the first UK-wide COVID-19 enforced national lockdown. OBJECTIVE: To assess the number, type and outcome of radiological investigations for children presenting to hospital with suspected physical abuse (SPA; including abusive head trauma) during the first national COVID-19 enforced lockdown compared with the prelockdown period. DESIGN: Multicentre, retrospective, observational, interrupted time series analysis. SETTING: Eight secondary/tertiary paediatric centres between January 2018 and July 2020 inclusive. PARTICIPANTS: 1587 hospital assessed children undergoing radiographic skeletal surveys (SkS) and head CT imaging performed for SPA/child protection concerns. MAIN OUTCOME MEASURES: Incidence and severity of fractures identified on SkS; head injury (composed of incidence rates and ratios of skull fracture, intracranial haemorrhage (ICH) and hypoxic ischaemic injury (HII)) on head CT imaging; and ratio of antemortem and postmortem SkS. RESULTS: 1587 SkS were performed: 1282 (81%) antemortem, 762 (48%) male, and positive findings in 582 (37%). Median patient age was 6 months. There were 1.7 fractures/child prelockdown versus 1.1 fractures/child during lockdown. There was no difference between positive/negative SkS rates, the absolute ratio of antemortem/postmortem SkS or absolute numbers of head injury occurring between January 2018 and February 2020 and the lockdown period April-July 2020. Likewise, prelockdown incidence and rates of skull fracture 30/244 (12%), ICH 28/220 (13%) and HIE 10/205 (5%) were similar to lockdown, 142/1304 (11%), 171/1152 (15%) and 68/1089 (6%), respectively. CONCLUSION: The first UK COVID-19 lockdown did not lead to an increase in either the number of antemortem or postmortem radiological investigations performed for SPA, or the number or severity of fractures and intracranial injuries identified by these investigations.

Child Abuse Imaging and Findings in the Time of COVID-19.

OBJECTIVE: To assess the impact of the COVID-19 pandemic on physical abuse in young children, we compared the following before and during the pandemic: (1) skeletal survey volume, (2) percent of skeletal surveys revealing clinically unsuspected (occult) fractures, and (3) clinical severity of presentation. We hypothesized that during the pandemic, children with minor abusive injuries would be less likely to present for care, but severely injured children would present at a comparable rate to prepandemic times. We expected that during the pandemic, the volume of skeletal surveys would decrease but the percentage revealing occult fractures would increase and that injury severity would increase. METHODS: We conducted a retrospective study of children younger than 2 years undergoing skeletal surveys because of concern for physical abuse at a tertiary children's hospital. Subjects were identified by querying a radiology database during the March 15, 2019-October 15, 2019 (pre-COVID-19) period and the March 15, 2020-October 15, 2020 (COVID-19) period, followed by chart review to refine our population and abstract clinical and imaging data. RESULTS: Pre-COVID-19, 160 skeletal surveys were performed meeting the inclusion criteria, compared with 125 during COVID-19, representing a 22% decrease. No change was observed in identification of occult fractures (6.9% pre-COVID vs 6.4% COVID, P = 0.87). Clinical severity of presentation did not change, and child protective services involvement/referral decreased during COVID. CONCLUSIONS: Despite a >20% decrease in skeletal survey performance early in the pandemic, the percent of skeletal surveys revealing occult fractures did not increase. Our results suggest that decreases in medical evaluations for abuse did not stem from decreased presentation of less severely injured children.

The impact of the consensus statement on abusive head trauma in infants and young children.

It seems paradoxical that facts, data and science are still considered controversial despite the harrowing death of a multitude of people from coronavirus disease 2019 (COVID-19), an unparalleled health care crisis of our lifetime. In addition, while scientists are desperately attempting to produce a vaccine for COVID-19, a large segment of the populace still believes in conspiracies related to vaccines. Therefore, it is not surprising that the diagnosis of abusive head trauma (AHT) faces similar challenges - the difference being that AHT challenges are mostly in the realms of law courts rather than actual clinical management of these infants. Against this backdrop, the Child Abuse Imaging Committee of the Society for Pediatric Radiology (SPR) collaborated with other leading experts to develop the consensus statement on AHT. This consensus statement has had a significant impact since its publication. It is now endorsed by 17 multinational, multidisciplinary organizations. The consensus statement has helped educate the diverse stakeholders of AHT and has helped further our understanding of AHT and the issues related to it. This could serve as the template for developing future consensus documents.

Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic - United States, January 2019-September 2020.

Heightened stress, school closures, loss of income, and social isolation resulting from the coronavirus disease 2019 (COVID-19) pandemic have increased the risk for child abuse and neglect (1). Using National Syndromic Surveillance Program (NSSP) data from January 6, 2019-September 6, 2020, CDC tabulated weekly numbers of emergency department (ED) visits related to child abuse and neglect and calculated the proportions of such visits per 100,000 ED visits, as well as the percentage of suspected or confirmed ED visits related to child abuse and neglect ending in hospitalization, overall and stratified by age group (0-4, 5-11, and 12-17 years). The total number of ED visits related to child abuse and neglect began decreasing below the corresponding 2019 period during week 11 (March 15-March 22, 2020) for all age groups examined, coinciding with the declaration of a national emergency on March 13 (2); simultaneously, the proportion of these visits per 100,000 ED visits began increasing above the 2019 baseline for all age groups. Despite decreases in the weekly number of ED visits related to child abuse and neglect, the weekly number of these visits resulting in hospitalization remained stable in 2020; however, the yearly percentage of ED visits related to child abuse and neglect resulting in hospitalization increased significantly among all age groups. Although the increased proportion of ED visits related to child abuse and neglect might be associated with a decrease in the overall number of ED visits, these findings also suggest that health care-seeking patterns have shifted during the pandemic. Hospitalizations for child abuse and neglect did not decrease in 2020, suggesting that injury severity did not decrease during the pandemic, despite decreased ED visits. Child abuse is preventable; implementation of strategies including strengthening household economic supports and creating family-friendly work policies can reduce stress during difficult times and increase children's opportunities to thrive in safe, stable, and nurturing relationships and environments (3).

Increased child abuse in Uganda amidst COVID-19 pandemic.

Globally, COVID-19 lockdown measures have exposed children to more sexual, physical and emotional abuse and neglect. Although the COVID-19 pandemic is likely to have long-lasting adverse psychological effects on children, there have been comparatively few studies on children's health as compared with adults, particularly in low-income countries. Uganda implemented one of the most stringent lockdowns with bans on transportation and gatherings as well as the closure of schools, stores and places of worship. In order to address the dearth of information in less developed regions, the article aims to provide an insight into the increased cases of child abuse in Uganda during the COVID-19 pandemic. The data and information were primarily compiled from government and child welfare organisation open-source databases. The psychosocial impacts of COVID-19 have greatly disrupted the living conditions of children, limiting their access to basic needs such as food and health care. In addition, there is a lack of social support, thus putting children at an increased risk of different forms of child abuse. Since the implementation of the COVID-19 lockdown in Uganda, there has been a rise in the incidence of child abuse. Increased cases of physical and sexual abuse against children have been reported in different parts of the country as well as increased cases of child labour. To strengthen child protection during the COVID-19 pandemic, this article highlights a need for multi-level stakeholder cooperation to ensure increased funding, increased community awareness and sensitisation, early detection and effective management and referral of child abuse cases.

Reporting of child maltreatment during the SARS-CoV-2 pandemic in New York City from March to May 2020.

BACKGROUND: School closures and other public health responses have decreased the extent that children interact with mandated reporters and other professionals trained to detect child maltreatment. OBJECTIVE: To assess associations between the pandemic public health response and the number of allegations of child abuse or neglect. METHODS: This study analyzed monthly data from New York City of the number of child maltreatment allegations, stratified by reporter type (e.g., mandated reporter, education personnel, healthcare personnel), as well as the number of Child Protective Services (CPS) investigations warranting child welfare preventative services. SARIMA models were trained using data from January 2015 to February 2020 to predict expected values for March, April, and May 2020. Observed values were compared against predicted values at an alpha of .05. RESULTS: Substantially fewer allegations of child maltreatment were reported than expected in March (-28.8 %, deviation: 1848, 95 % CI: [1272, 2423]), April (-51.5 %, deviation: 2976, 95 % CI: [2382, 3570]), and May 2020 (-46.0 %, deviation: 2959, 95 % CI: [2347, 3571]). Significant decreases in child maltreatment reporting were also noted for all reporter subtypes examined for March, April, and May 2020. Fewer CPS investigations warranted preventative services than expected in March 2020 (-43.5 %, deviation: 303, 95 % CI: [132, 475]). CONCLUSIONS: Precipitous drops in child maltreatment reporting and child welfare interventions coincided with social distancing policies designed to mitigate COVID-19 transmission. In light of these findings, educators and healthcare providers must be especially vigilant when engaging online with children and their families for signs of child abuse and/or neglect.

Physical child abuse demands increased awareness during health and socioeconomic crises like COVID-19.

Background and purpose - Physical abuse of children, i.e., nonaccidental injury (NAI) including abusive head trauma (AHT) is experienced by up to 20% of children; however, only 0.1% are diagnosed. Healthcare professionals issue less than 20% of all reports suspecting NAI to the responsible authorities. Insufficient knowledge concerning NAI may partly explain this low percentage. The risk of NAI is heightened during health and socioeconomic crises such as COVID-19 and thus demands increased awareness. This review provides an overview and educational material on NAI and its clinical presentation.Methods - We combined a literature review with expert opinions of the senior authors into an educational paper aiming to help clinicians to recognize NAI and act appropriately by referral to multidisciplinary child protection teams and local authorities.Results - Despite the increased risk of NAI during the current COVID-19 crisis, the number of reports suspecting NAI decreased by 42% during the lockdown of the Danish society. Healthcare professionals filed only 17% of all reports of suspected child abuse in 2016.Interpretation - The key to recognizing and suspecting NAI upon clinical presentation is to be aware of inconsistencies in the medical history and suspicious findings on physical and paraclinical examination. During health and socioeconomic crises the incidence of NAI is likely to peak. Recognition of NAI, adequate handling by referral to child protection teams, and reporting to local authorities are of paramount importance to prevent mortality and physical and mental morbidity.