Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation.

OBJECTIVE: Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). METHODS: Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS: Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. CONCLUSIONS: Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.

A Standardized Peer Review Program Improves Assessment and Documentation of Child Sexual Abuse.

INTRODUCTION: The objective was to assess the impact of interventions associated with ongoing expert peer review on the quality of child abuse medical providers' written and photograph documentation in child sexual abuse cases. METHODS: Pediatricians participated in a HIPAA compliant blind peer review process on a web platform developed to provide the American Board of Pediatrics maintenance of certification. Participants submit sequential photograph and written documentation of child sexual abuse examinations over 1 year. Documentation includes genital examination descriptions and interpretation of findings. Reviewers evaluate the photographic quality and written documentation of examination findings utilizing a numerical rating system. Each case cycle is reviewed by one of four experts in child abuse who received training in a uniform evaluation process. Reviewers follow each case throughout three cycles of documentation, selecting from several interventions that have been customized to address the quality issues noted. The third and final cycle includes summary comments from the reviewer. RESULTS: Forty-one participants completed the program at the time these data were collected. A paired t test analysis of the combined scores of the three measures, such as Image Quality, Quality of Written Documentation, and Accuracy of Exam Interpretation, showed a statistically significant improvement (P < 0.001) between the first and last sets. In addition, each of the individual measures was statistically significant between the first and last case sets with a P value of <0.05 for each. CONCLUSION: Peer review with interventions customized to address quality issues improved the quality of the assessment and documentation of child sexual abuse evaluations.

A changing history: When is it a red flag for child abuse?

BACKGROUND AND OBJECTIVE: While a changing history is frequently cited as a red flag for child abuse, no data support which changes are significant, nor the degree to which concern should be increased. We sought to measure the impact of changing caregiver histories on expert assessments of abuse likelihood. METHODS: We used a vignette survey to measure the impact of a changing history on child abuse expert assessments of abuse likelihood and willingness to undertake testing and protective interventions. By randomly varying the presence and magnitude of history changes, we determined their impact on perceived abuse likelihood. RESULTS: Of 494 invited participants, 267 (54 %) completed the survey. The presence of historical changes significantly affected experts' level of concern for abuse and willingness to test or report abuse, though to variable degrees. For example, while a minor change in the timing of an injury did not significantly increase willingness to perform a skeletal survey (OR: 1.5, 95 % CI: 0.8-2.9), a major change in the timing of an injury did (OR: 2.0, 95 % CI: 1.1-3.6). In addition, a change from having no initial history of trauma to then giving a history of accidental trauma significantly lowered the mean estimate of abuse likelihood and triggered significantly less reports to child protective services (OR: 0.02, 95 % CI: 0.003-0.2). CONCLUSION: For abuse experts, some history changes are more concerning than others, with major changes in history, and an initial denial of trauma having the largest impact. Future research regarding changing histories should consider details of the change, rather than treating all changes equally.

Patterned Bruises From Abusive Squeezing.

ABSTRACT: Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in "grab mark" contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.

When Medical Care and Parents Collide-Parents Who Refuse Testing and or Treatment for Children.

Medical Neglect is a challenging diagnosis. Physicians and parents may clash over what they both perceive to be in the best interest of the child. Cultural, religious, financial, or philosophical differences between the health care providers and families can be difficult to negotiate. This paper reviews the definition of medical neglect and describes barriers that can prevent families from following medical recommendations for their child. Involvement of statutory authorities to intervene in cases of medical neglect may be helpful, but also may result in increased friction between parents and the health system, often without a satisfactory outcome for the child. Recognizing and then overcoming such barriers, as well as improving communication can help the family to begin to cooperate with medical recommendations. The paper will present an approach to families, parameters for reporting when all other options have failed, and the child remains at risk for harm due to the failure of the parent or caregiver to follow medical advice. The ultimate goal of any intervention is to ensure that children can achieve their full potential, in a nurturing and caring environment.

Classic metaphyseal lesion of distal tibia following footling breech delivery.

Classic metaphyseal lesions associated with childbirth are rare. We report a distal tibial metaphyseal fracture following a difficult breech delivery. Classic metaphyseal fractures are considered highly specific injuries associated with non-accidental trauma. This case depicts a classic metaphyseal lesion sustained during footling breech extraction in an urgent delivery. The traction and torque placed on the distal extremities during this difficult delivery suggest a potential mechanism for this injury.

Susceptibility-weighted imaging of retinal hemorrhages in abusive head trauma.

BACKGROUND: Retinal hemorrhages are one of the most important supportive evidences for abusive head trauma (AHT). Susceptibility-weighted imaging (SWI) is highly suited to identify various forms of intracranial hemorrhage in AHT. However its utility in imaging retinal hemorrhage is not well established. OBJECTIVE: SWI is a sensitive sequence for identifying retinal hemorrhage on MRI. MATERIALS AND METHODS: In this retrospective analysis, 26 consecutive infants and young children with a suspected admission diagnosis of AHT underwent indirect ophthalmoscopy and brain MRI protocol for AHT along with SWI. Brain susceptibility-weighted images of 14 age-matched children were used as controls. For detecting retinal hemorrhage, susceptibility-weighted images of patients and controls were reviewed randomly and independently by two neuroradiologists who were blinded to the history and ophthalmology findings. A pediatric ophthalmologist graded the indirect ophthalmoscopy images. RESULTS: A diagnosis of AHT was confirmed in all 26 cases from a multidisciplinary meeting. Indirect ophthalmoscopy images were available in 21 cases. Ophthalmoscopy was positive for retinal hemorrhage in the right eye in 18 cases (85.7%) and in the left eye in 16 cases (76.2%). On SWI, retinal hemorrhage was identified in the right eye in 9/21 cases (42.8%) and in the left eye in 8/21 cases (38.1%) of AHT. Analysis of SWI in 21 cases of AHT demonstrated a sensitivity of 50%, specificity of 100%, positive predictive value of 100% and negative predictive value of 32% for detecting retinal hemorrhage. CONCLUSION: SWI is moderately sensitive and highly specific for identifying retinal hemorrhage in AHT. Further studies are needed to identify steps to improve the efficiency of SWI in detecting retinal hemorrhage.

Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused.

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

International issues in abusive head trauma.

In the decades since Dr. John Caffey described a series of children with chronic subdural hematoma and long bone fractures, there has been a substantial increase in the medical recognition of various forms child abuse. In the United States, the term shaken baby syndrome was coined to explain a constellation of injuries assumed to be the result of violent shaking of infants. After improved understanding of the variety of mechanisms that occur when children are abused, abusive head trauma (AHT) has become the recommended terminology. AHT is a more comprehensive term that reflects the brain injuries that children suffer as the result of abuse. AHT continues to include shaking as a mechanism of injury as well as shaking with impact, impact alone, crushing injuries or combinations of several mechanisms. The medical community in the United States has led the way in developing new terminology and research to describe this unique and devastating form of abuse. The globalization of medicine and rapid information transfer has resulted in AHT becoming well-recognized internationally as a form of serious and fatal child abuse. This paper will review the historical basis in the United States for the diagnosis of AHT. We will also review some of the current international issue in epidemiology, diagnosis, legal processes and outcomes in selected countries/regions where child abuse physicians are actively involved in the evaluation of AHT.

Inter-rater reliability in child sexual abuse diagnosis among expert reviewers.

OBJECTIVES: To determine how well experts agree when assessing child sexual abuse cases. METHODS: A total of twelve physician subjects were recruited and voluntarily enrolled from an existing peer review network. Experts from the network had been chosen for their experience in the field and their affiliation with children's advocacy centers. Each expert submitted three cases of prepubertal female genital examinations clearly demonstrable of the case findings. Submitted cases included demographics, history, physical and genital exam findings, photodocumentation, and diagnosis. Experts reviewed each submitted case and labeled the case negative for physical finding(s), positive for physical finding(s), or indeterminate. Cases were analyzed to determine the level of agreement. RESULTS: Thirty-six cases were submitted for use in this study; one case was excluded prior to starting the review process. After all experts completed their reviews the authors reviewed the cases and results. Two additional cases were excluded, one due to poor quality photodocumentation and one for not meeting the study criteria. Thirty-three cases were used for data analysis. All 12 expert reviewers agreed in 15 of the cases. Overall, in 22 of 33 (67%) cases at least 11 of the 12 reviewers agreed with the original diagnosis. Six of 33 (18%) cases had variable agreement (8-10 reviewers agreed with original diagnosis) among reviewers; 5 of 33 (15%) cases had poor or mixed agreement (7 or less reviewers agreed with original diagnosis). CONCLUSIONS: Experts exhibit consensus in cases where the findings clearly are normal and abnormal, but demonstrate much more variability in cases where the diagnostic decisions are less obvious. Most of the diagnostic variability is due to interpretation of the findings as normal, abnormal or indeterminate, not on the perception of the examination findings themselves. More research should be done to develop a national consensus on the accurate interpretation of anogenital examination findings. Photographic image quality plays an important role in this quality review process and universally needs to be improved.

Diagnostic accuracy in child sexual abuse medical evaluation: role of experience, training, and expert case review.

OBJECTIVES: (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions. METHODS: Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey. RESULTS: The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008). CONCLUSIONS: Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse.

Development of standardized clinical training cases for diagnosis of sexual abuse using a secure telehealth application.

OBJECTIVES: The training of physicians, nurse examiners, social workers and other health professional on the evidentiary findings of sexual abuse in children is challenging. Our objective was to develop peer reviewed training cases for medical examiners of child sexual abuse, using a secure web based telehealth application (TeleCAM). METHODS: Sixty de-identified cases developed by 2 child abuse pediatricians, were stratified by availability of information (minimal, moderate, comprehensive) for both positive and negative child sexual abuse findings. These cases were narrowed to a set of 30 cases through an expert peer review process using pediatricians with extensive expertise in the evaluation of child sexual abuse. A previously studied secure web-based telehealth application TeleCAM which contains a child abuse workflow, was used to develop, disseminate and review cases. A series of Free Margin agreement statistics are used to select those cases with the highest rates of agreement. A final set of 30 cases are stratified equally by availability of information and for both positive and negative findings. Mantel Haenszel Chi-square was used for trend analysis of the ordered categorical variables. RESULTS: The highest degrees of inter-rater reliability was found in cases with moderate to comprehensive information. Cases with minimal data had poor kappa agreement indicating that availability of differing levels and types of information contribute to variability in diagnostic findings. CONCLUSION: These final cases will be further studied with medical examiners in various settings utilizing TeleCAM as the application for dissemination.

Neuroimaging of abusive head trauma.

The diagnostic process for evaluating suspected abusive head trauma in infants and children has evolved with technological advances in neuroimaging. Since Caffey first described a series of children with chronic subdural hematomas and multiple long bone fractures, radiologists have played an important role, along with pediatricians and pathologists, in evaluating abused children. Neuroimaging modalities include ultrasound, CT scans, and MRI technology. Each has distinct clinical applications, as well as practical uses in the clinical diagnostic process of AHT. Importantly, neuroimaging assists in the process of differential diagnosis of other conditions which may mimic AHT. Collaboration between neuroradiologists, clinicians, and pathologists remains critical to making the appropriate diagnosis. Careful history, physical examination, and investigation by legal authorities form the components that result in accurate assessment of any case. This paper reviews pertinent neuroimaging modalities currently utilized in the diagnosis of AHT, describing clinical indications and a collaborative approach to this process.

Abusive head trauma in infants and young children: a unique contributor to developmental disabilities.

Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.

Retinal hemorrhages in an 8-year-old child: an uncommon presentation of abusive injury.

OBJECTIVE: Retinal hemorrhages in pediatric patients have been best described as a component of shaken baby syndrome (SBS), which has been described almost exclusively in the infant/toddler population. We describe the occurrence of retinal hemorrhages in the setting of abusive injury in an older child. METHODS: Case report. RESULTS: An 8-year-old boy was transferred to our institution with coma and respiratory arrest. Evaluation demonstrated intracranial hemorrhage, cerebral edema, and severe bilateral retinal hemorrhages. The patient subsequently died of intractable intracranial hypertension. Police investigation confirmed that the injuries were caused by severe abusive injury, including shaking. CONCLUSIONS: This case emphasizes that the diagnosis of SBS is not limited to babies and that the possibility of abusive shaking injury should also be considered in older children presenting with intracranial pathology and retinal hemorrhages.