Recognizing, diagnosing, and preventing child maltreatment: an update for pediatric clinicians.

PURPOSE OF REVIEW: Despite an increasing understanding of the impact of emotional trauma and physical abuse on children, clinicians and hospitals still sometimes miss the diagnosis of abuse. The literature in 2017 focused on creating standardized approaches to recognition and diagnosis of physical abuse and occult injury, including using the electronic medical record to provide triggers for consultation of the hospital Child Protection Program. The American College of Radiology updated their standardized approach to the evaluation of physical abuse in the child, and other authors gave us screening tools for commercial exploitation, as well as guidance about how to recognize risks for emotional abuse in families. The opioid epidemic and legalization of marijuana are both impacting children, and providers are searching for ways to provide support for parents with substance use disorders whilst considering the safety of children.This article reviews relevant publications during the past year about issues of child maltreatment. It is intended to guide those providers in primary care or other medical disciplines who care for children and families. RECENT FINDINGS: Child maltreatment cases are still not always diagnosed, either because of provider bias (leading to under evaluation), or because clinicians lack experience or understanding of proper evaluation approaches. There are many new tools to assist in recognition of abuse, including screening instruments and flags that can be used in the electronic medical record to trigger a consult with the Child Protection Program. The evaluation and diagnosis of sexual abuse continues to evolve, with the literature providing advice about what is or is not normal on physical exam, as well as advice for providers who work with adolescent sexual assault victims. The debate about the validity of abusive head trauma (AHT) diagnoses continues, with sweden being the most recent center of controversy. With the opioid epidemic having such a significant effect on families and children, clinicians are struggling to support parents with substance use disorder while protecting children from the impact of their parents' disease. SUMMARY: The past year in child abuse literature has yielded increased clarity in screening and diagnostic recommendations across the fields of physical abuse, AHT, sexual abuse, and commercial sexual exploitation of children (CSEC). The body of literature surrounding emotional abuse and neglect continues to grow, especially in light of the burgeoning opioid epidemic. Critically, the year's research reflects an evolving understanding of effective prevention and intervention initiatives to address child maltreatment.

Child maltreatment: a review of key literature in 2015.

PURPOSE OF REVIEW: This review addresses some of the more salient articles in the field of child maltreatment published in 2015, with a goal of helping the general practitioner understand the evolution of research in the field of child abuse pediatrics (a board-certified specialty since 2009). RECENT FINDINGS: Researchers continue to refine the database for child abuse pediatrics. Several articles focus on the inconsistencies in approach to the evaluation of possible physical child abuse between hospitals and practitioners. Multiple researchers aim to develop a protocol that standardizes the response to findings of a sentinel injury, such as a rib fracture, abdominal trauma, or unexplained bruising in a nonambulatory infant. Professionals are also working to improve our understanding about the impact of trauma on children and how best to ameliorate its effects. SUMMARY: With solid, evidence-based literature published on various topics in the field of child abuse pediatrics, experts work to refine and unify the clinician's approach to the evaluation of possible physical abuse.

Retroclival collections associated with abusive head trauma in children.

Retroclival collections are rare lesions reported almost exclusively in children and strongly associated with trauma. We examine the incidence and imaging characteristics of retroclival collections in young children with abusive head trauma. We conducted a database search to identify children with abusive head trauma ≤ 3 years of age with brain imaging performed between 2007 and 2013. Clinical data and brain images of 65 children were analyzed. Retroclival collections were identified in 21 of 65 (32%) children. Ten (48%) were subdural, 3 (14%) epidural, 2 (10%) both, and 6 (28%) indeterminate. Only 8 of 21 retroclival collections were identifiable on CT and most were low or intermediate in attenuation. Eighteen of 21 retroclival collections were identifiable on MRI: 3 followed cerebral spinal fluid in signal intensity and 15 were bloody/proteinaceous. Additionally, 2 retroclival collections demonstrated a fluid-fluid level and 2 enhanced in the 5 children who received contrast material. Sagittal T1-weighted images, sagittal fluid-sensitive sequences, and axial FLAIR (fluid-attenuated inversion recovery) images showed the retroclival collections best. Retroclival collections were significantly correlated with supratentorial and posterior fossa subdural hematomas and were not statistically correlated with skull fracture or parenchymal brain injury. Retroclival collections, previously considered rare lesions strongly associated with accidental injury, were commonly identified in this cohort of children with abusive head trauma, suggesting that retroclival collections are an important component of the imaging spectrum in abusive head trauma. Retroclival collections were better demonstrated on MRI than CT, were commonly identified in conjunction with intracranial subdural hematomas, and were not significantly correlated with the severity of brain injury or with skull fractures.

Child maltreatment: a review of key literature in 2013.

PURPOSES OF REVIEW: This review summarizes new findings in the field of maltreatment, addressing epidemiology, physical abuse, abusive head trauma, sexual abuse, sequelae, and prevention. RECENT FINDINGS: Many articles this year focus on establishing a framework for thinking about how to evaluate a child for maltreatment, the consequences of maltreatment, and the current understanding of prevention efforts. Interestingly, some research has helped to reinforce some concepts that were clinically appreciated, especially related to retinal hemorrhages. SUMMARY: The volume, quality, and breadth of research relating to child maltreatment continue to improve and expand our understanding of child abuse pediatrics. These authors summarize notable advances in our understanding of child maltreatment over the past year.

Recurrent concerns for child abuse: repeated consultations by a subspecialty child abuse team.

Physically abused children may be repeatedly reported to child protection services and undergo multiple medical evaluations. Less is known about recurrent evaluations by hospital-based child abuse teams for possible abuse. The objectives of this study were to determine the frequency of repeated consultations by child abuse teams and to describe this cohort in terms of injury pattern, perceived likelihood of abuse, disposition plan, and factors related to repeat consultation. This was a prospectively planned, secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) research network. Subjects included children younger than 10 years of age who were referred to child abuse subspecialty teams at one of 20 U.S. academic centers. Repeat consultations occurred in 101 (3.5%; 95% CI 2.9-4.2%) of 2890 subjects. The incidence of death was 4% (95% CI 1-9%) in subjects with repeated consults and 3% (95% CI 2-3%) in subjects with single consults. Perceived likelihood of abuse from initial to repeat visit remained low in 33% of subjects, remained high in 24.2% of subjects, went from low to high in 16.5%, and high to low in 26.4% of subjects. Themes identified among the subset of patients suspected of repeated abuse include return to the same environment, failure to comply with a safety plan, and abuse in foster care. Repeated consultation by child abuse specialists occurs for a minority of children. This group of children may be at higher risk of subsequent abuse and may represent an opportunity for quality improvement.

Child maltreatment: promising approaches and new directions.

PURPOSE OF REVIEW: This review summarizes the key articles in the field of child maltreatment, addressing abusive head trauma, physical abuse, sexual abuse, and global issues surrounding maltreatment. This topic is salient for both general pediatricians as well as specialists. RECENT FINDINGS: Many articles this year focus on the importance of making an accurate diagnosis when considering child maltreatment, whether in the form of physical or sexual abuse. There is also a focus on understanding the epidemiology of abuse, as some data show a decrease in numbers, which is felt by many in the field to be a misleading impression. SUMMARY: An appreciation of the scope of Child Abuse Pediatrics requires an understanding of physical abuse, sexual abuse, and neglect. The authors summarize notable advances in our understanding of these key areas in a review of the year's best literature.

Three-dimensional skull models as a problem-solving tool in suspected child abuse.

BACKGROUND: The value of 3-D skull models in evaluation of young children with suspected child abuse is not known. OBJECTIVE: The purpose of this study was to assess the value of 3-D skull models as a problem-solving tool in children younger than 2 years. MATERIALS AND METHODS: We performed a retrospective study on 73 children (ages 0-24 months) seen by a child protection team (CPT) who were undergoing head CT between August 2007 and July 2009. RESULTS: Of the 73 children, volume-rendered 3-D models were obtained in 26 (35.6%). Three-dimensional models changed initial CT interpretation in nine instances (34.6%). Findings thought to be fractures were confirmed as normal variants in four children. Depressed fractures were correctly shown to be ping-pong fractures in two cases. In one case, an uncertain finding was confirmed as a fracture, and an additional contralateral fracture was identified in one child. A fracture seen on skull radiographs but not seen on axial CT images was identified on the 3-D model in one case. Changes in interpretation led to modification in management in five children. CONCLUSION: Use of 3-D skull models can be a problem-solving tool when there is discordance among the CT reading, subsequent radiographic investigations and clinical evaluation.

Child abuse pediatrics: prevention, evaluation, and treatment.

PURPOSE OF REVIEW: This review is designed to update the general pediatrician with information about current child maltreatment literature. The authors have selected salient articles, which inform daily practice of any professional involved in the care of children who may be at risk of child abuse. RECENT FINDINGS: The field of child abuse pediatrics continues to engender controversy in both medical journals and courtrooms. As scrutiny about the basis for the diagnosis increases, clinicians and researchers work to build a solid base of scientific evidence with thorough and well-designed studies. This is most evident with regards to abusive head trauma, wherein both lay and scientific press challenge the possibility that infants can be severely injured or killed by shaking, blunt force trauma, or both. SUMMARY: Child abuse pediatrics is a well-established and credible medical field. Although child physical and sexual abuse are age-old problems, public acknowledgement and intervention models are relatively new, and medical literature continues to reflect an increasing and deeper understanding of the impact of abuse throughout the world.

Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse.

OBJECTIVE: The purpose of this article is to determine the relative likelihood of encountering a classic metaphyseal lesion in infants at low and high risk for abuse. MATERIALS AND METHODS: This 10-year retrospective study compared the prevalence of the classic metaphyseal lesion on high-detail American College of Radiology-standardized skeletal surveys in infants at low and high risk for abuse. Low-risk infants met all of the following criteria: skull fracture without significant intracranial injury on CT, history of a fall, and no other social risk factors for abuse. High-risk infants met all of the following criteria: significant intracranial injury, retinal hemorrhages, and skeletal injuries (excluding classic metaphyseal lesions and skull fractures). Differences between the two groups were calculated using the Fisher exact test. RESULTS: There were 42 low-risk infants (age range, 0.4-12 months; mean age, 4.4 months) and 18 high-risk infants (age range, 0.8-10.3 months; mean age, 4.6 months). At least one classic metaphyseal lesion was identified in nine infants (50%) in the high-risk category. No classic metaphyseal lesions were identified in the low-risk group. The relative prevalence of classic metaphyseal lesions in the low-risk group (0/42) versus that in the high-risk group (9/18) was statistically significant (p < 0.0001; 95% CI, 0-8% to 29-76%). CONCLUSION: Classic metaphyseal lesions are commonly encountered in infants at high risk for abuse and are rare in infants with skull fractures associated with falls, but no other risk factors. The findings support the view that the classic metaphyseal lesion is a high-specificity indicator of infant abuse.

Update on child maltreatment: toward refining the evidence base.

PURPOSE OF REVIEW: This review is designed to aid general pediatricians as they assess cases of possible child maltreatment. The authors have selected salient articles that inform the daily practice of any professional involved in assessing child abuse. RECENT FINDINGS: The incidence of child abuse continues to decline in the United States, although a large number of children still suffer from abuse and neglect, and many are subject to more than one type of maltreatment. Clinicians are encouraged to be vigilant about the subtle indicators of physical abuse, with many authors adding to our understanding about how children present after inflicted abdominal or skeletal trauma. Clinicians are also cautioned to watch for signs of Munchausen syndrome by proxy, which may be elusive and difficult to discern. SUMMARY: The field of child abuse pediatrics is still young, with the first board certification in 2009. The volume of research in the field is exploding and there is a greater level of awareness and data collection occurring throughout the world. Pediatric clinicians are encouraged to play a role in preventing abuse and neglect, as well as addressing intimate partner violence, and to maintain vigilance about child maltreatment and its subtle clinical presentations.

Whole-body MRI in suspected infant abuse.

OBJECTIVE: The purpose of our study was to examine the utility of whole-body MRI (WB-MRI) in the detection of skeletal and soft-tissue injuries in suspected infant abuse. MATERIALS AND METHODS: Twenty-one infants (0-12 months) underwent WB-MRI for evaluation of suspected child abuse. WB-MRI at 1.5 T was performed using coronal and sagittal STIR sequences within 5 days of initial skeletal survey. Follow-up skeletal survey was performed in 16 cases. The "truth" was determined by integrating the initial and follow-up skeletal surveys, where available, into a summary of skeletal injuries (summary skeletal survey). Statistics included analysis of counts and proportions, concordance rate, sensitivity, and specificity. RESULTS: Summary skeletal survey and WB-MRI identified 167 fractures or areas of skeletal signal abnormality: 46 (27.5%) by both techniques, 68 (40.7%) by summary skeletal survey only, and 53 (31.7%) by WB-MRI only. WB-MRI had high specificity (95%) but low sensitivity (40%) for identifying fractures or signal abnormalities compared with summary skeletal survey. Thirty-seven classic metaphyseal lesions or metaphyseal signal abnormalities were identified: 11 (29.7%) by both techniques, 24 (64.8%) by summary skeletal survey only, and two (5.4%) by WB-MRI only. WB-MRI had very low sensitivity (31%) for identifying signal abnormality where classic metaphyseal lesions were seen with skeletal survey. WB-MRI had low sensitivity (57%) for identifying signal abnormality in areas where rib fractures were seen on skeletal survey. WB-MRI identified soft-tissue injuries such as muscle edema and joint effusions that, in some cases, led to identifying additional fractures. CONCLUSION: WB-MRI is insensitive in the detection of classic metaphyseal lesions and rib fractures, high specificity indicators of infant abuse. WB-MRI cannot replace the skeletal survey but may complement it by identifying soft-tissue abnormalities.

Skeletal trauma in child abuse: detection with 18F-NaF PET.

PURPOSE: To evaluate the sensitivity of fluorine 18-labeled sodium fluoride ((18)F-NaF) positron emission tomography (PET) for assessment of skeletal trauma in pediatric patients suspected of having been abused and to compare the diagnostic performance of this examination with that of high-detail skeletal survey. MATERIALS AND METHODS: The institutional review board approved this retrospective study and determined that it was in accordance with regulations of HIPAA privacy rule 45, Code of Federal Regulations parts 160 and 164, and that the criteria for waived patient authorization were met. The baseline skeletal survey and PET images obtained in 22 patients younger than 2 years between September 2007 and January 2009 were reviewed. Fourteen patients also underwent follow-up skeletal survey. The PET images were interpreted by two pediatric nuclear medicine physicians. The initially obtained skeletal survey images were interpreted blindly by a pediatric radiologist. A second pediatric radiologist interpreted the follow-up skeletal survey images in conjunction with the baseline survey images and rendered a final interpretation for the 14 patients in whom both baseline and follow-up skeletal survey data were available, which served as the reference standard. RESULTS: A total of 156 fractures were detected at baseline skeletal survey, and 200 fractures were detected at PET. Compared with the reference standard (findings in the 14 patients who underwent baseline and follow-up skeletal survey), PET had sensitivities of 85% for the detection of all fractures, 92% for the detection of thoracic fractures (ribs, sternum, clavicle, and scapula), 93% for the detection of posterior rib fractures, and 67% for the detection of classic metaphyseal lesions (CMLs), defined as a series of microfractures across the metaphysis. Compared with the reference standard, baseline skeletal survey had sensitivities of 72% for the detection of all fractures, 68% for the detection of thoracic fractures, 73% for the detection of posterior rib fractures, and 80% for the detection of CMLs. CONCLUSION: (18)F-NaF PET had greater sensitivity in the overall detection of fractures related to child abuse than did baseline skeletal survey. (18)F-NaF PET was superior in the detection of rib fractures in particular. Thus, (18)F-NaF PET is an attractive choice for evaluation of suspected child abuse, an application in which high sensitivity is desirable. Because of the lower sensitivity of PET in the detection of CMLs, a characteristic fracture in child abuse, initial radiographic evaluation remains necessary.

Child abuse and neglect: a worldwide concern.

PURPOSE OF REVIEW: As knowledge about child abuse and neglect increases worldwide, so does the literature on abuse and neglect. The authors explore many studies published this year, with attention to the advances in understanding which are guiding prevention efforts as well as diagnosis and treatment of abuse and neglect. RECENT FINDINGS: The evidence base for many forms of child abuse continues to grow. Controversy around the diagnosis of child abuse still continues, with current debate focused on the diagnosis of abusive head injury and whether children with vitamin D deficiency are misdiagnosed with abusive fractures. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented, and researchers are evaluating these efforts with an eye to whether or not they really contribute to prevention. SUMMARY: The short-term and long-term impact of child maltreatment is significant not only for individuals but for families and communities in which abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children. However, it is clear that specialists in child abuse should also play a role in order for diagnosis and management of abuse to adhere to a high standard of care. This has been validated this year by the creation of Child Abuse Pediatrics as a board certified specialty in the United States. As knowledge about abuse and neglect grows, clinicians are focusing on prevention as well as diagnosis and treatment.

Metaphyseal fragmentation with physiologic bowing: a finding not to be confused with the classic metaphyseal lesion.

OBJECTIVE: The purpose of this study was to describe the varied appearances of metaphyseal fragmentation associated with physiologic bowing and to estimate their frequency in children undergoing radiographic evaluation. CONCLUSION: The results of this study suggest that metaphyseal fragmentation is occasionally encountered in children with physiologic bowing. Results of a systematic imaging assessment should minimize confusion of this innocent radiologic alteration with the classic metaphyseal lesion of child abuse.

Update on child maltreatment.

PURPOSE OF REVIEW: The authors explore the literature published in the past year addressing child maltreatment issues, including sexual abuse, physical child abuse, inflicted head trauma, and child abuse prevention. RECENT FINDINGS: The body of knowledge about child abuse and its mimics continues to expand. Evident in this year's literature is the challenge which the diagnosis of child abuse creates for clinicians. Although further strides are being made toward universal education of providers, it is clear that there is still a reluctance to report abuse to child welfare agencies. The legal repercussions of diagnosing abuse can be extensive, and there has been a proliferation of medical defense experts who disagree with the commonly accepted tenets of abusive injury and who are vocal in the literature. SUMMARY: It remains the responsibility of pediatric providers to consider child maltreatment in the differential diagnosis of any unexplained injury or medical problem. Several studies document the high rate of spanking, slapping or shaking children, and primary care clinicians may be the first professionals in a position to begin the evaluation for possible child maltreatment. Despite the natural hesitancy to diagnose abuse, clinicians have an ethical and moral obligation to address this issue both in their practice and in their communities. The short-term and long-term costs to individuals who experience family violence have been well demonstrated and include not only emotional repercussions, but also chronic health conditions, which result in significant cost to society.

Pubic ramus radiolucencies in infants: the good, the bad, and the indeterminate.

OBJECTIVE: The purpose of this study was to examine imaging findings that differentiate inflicted injuries from developmental variants of the superior pubic ramus in healthy and abused infants. CONCLUSION: A superior pubic ramus fracture and a developmental variant can be difficult to differentiate radiographically. A smoothly marginated vertical radiolucency of the superior pubic ramus detected without other features suggesting infant abuse should not be interpreted as a fracture.

Update on child maltreatment.

PURPOSE OF REVIEW: The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect. RECENT FINDINGS: The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq. SUMMARY: The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.