American Academy of Pediatrics. Committee on Child Abuse and Neglect and Committee on Community Health Services. Investigation and review of unexpected infant and child deaths.

Although there is a continuing need for timely review of child deaths, no uniform system exists for investigation in the United States. Investigation of a death that is traumatic, unexpected, obscure, suspicious, or otherwise unexplained in a child younger than 18 years requires a scene investigation and an autopsy. Review of these deaths requires the participation of pediatricians and other professionals, usually as a child death review team. An appropriately constituted team should evaluate the death investigation process, review difficult cases, and compile child death statistics.

Analysis of missed cases of abusive head trauma.

CONTEXT: Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children. OBJECTIVES: To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis. DESIGN: Retrospective chart review of cases of head trauma presenting between January 1, 1990, and December 31, 1995. SETTING: Academic children's hospital. PATIENTS: One hundred seventy-three children younger than 3 years with head injuries caused by abuse. MAIN OUTCOME MEASURES: Characteristics of head-injured children in whom diagnosis of AHT was unrecognized and the consequences of the missed diagnoses. RESULTS: Fifty-four (31.2%) of 173 abused children with head injuries had been seen by physicians after AHT and the diagnosis was not recognized. The mean time to correct diagnosis among these children was 7 days (range, 0-189 days). Abusive head trauma was more likely to be unrecognized in very young white children from intact families and in children without respiratory compromise or seizures. In 7 of the children with unrecognized AHT, misinterpretation of radiological studies contributed to the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%) experienced medical complications related to the missed diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been prevented by earlier recognition of abuse. CONCLUSION: Although diagnosing head trauma can be difficult in the absence of a history, it is important to consider inflicted head trauma in infants and young children presenting with nonspecific clinical signs.

Comparison of intracranial computed tomographic (CT) findings in pediatric abusive and accidental head trauma.

BACKGROUND: Child abuse specialists rely heavily on diagnostic neuroimaging. OBJECTIVES: Study objectives were: (1) to compare the frequencies of six specific intracranial CT abnormalities in accidental and non-accidental pediatric head trauma, and (2) to assess interobserver agreement regarding these CT findings. MATERIALS AND METHODS: Three pediatric radiologists blindly and independently reviewed cranial CT scans of pediatric patients who sustained closed head trauma between 1991 and 1994. All patients were less than 4 years of age. Study cases included thirty-nine (50 %) with non-accidental head trauma and thirty-nine (50 %) with accidental head trauma. Each scan was evaluated for the presence or absence of the following six intracranial findings: (1) interhemispheric falx hemorrhage, (2) subdural hemorrhage, (3) large (non-acute) extra-axial fluid, (4) basal ganglia edema, (5) posterior fossa hemorrhage, and (6) frontal-parietal shearing tear(s). Interobserver agreement was calculated as the percentage of total cases in which all reviewers agreed a specific CT finding was present or absent. Diagnosis required independent agreement by all three pediatric radiologists. The frequencies of these six intracranial CT abnormalities were compared between the two study groups by Chi-square analysis and Fisher's exact test. RESULTS: Interobserver agreement between radiologists was greater than 80 % for all lesions evaluated, with the exception of frontal-parietal shearing tear(s). Interhemispheric falx hemorrhage, subdural hemorrhage, large (non-acute) extra-axial fluid, and basal ganglia edema were discovered significantly more frequently in non-accidental trauma (P

Child sexual abuse.

Multiple obstacles can hinder the medical evaluation of suspected child sexual abuse in pediatric primary care. The need for diagnostic accuracy is high. Knowledge of sexual abuse risk factors, an understanding of the victimization process, and awareness of the varied clinical presentations of sexual abuse can be of assistance. Open-ended questioning of the suspected victim is the most critical component of the evaluation. Skillful medical interviewing requires time, training, patience, and practice. Pediatricians lacking any of these four requirements should defer interviewing in sexual abuse cases to other professionals. Abnormal physical findings from sexual abuse are uncommon. Colposcopy has assisted pediatricians greatly in reaching consensus regarding diagnostic physical findings. Cases of acute sexual assault require familiarity with the forensic rape examination, STD screening and prophylaxis, and pregnancy prevention. Victimization from sexual abuse continues long after the abusive acts end, often requiring long-term therapeutic intervention. An emerging standard of care for medical evaluations of suspected child sexual abuse recognizes the requirement for patience and compassion while retaining objectivity. The pediatrician's primary concern must be for the child's physical and emotional well-being.

Coagulopathy in pediatric abusive head trauma.

OBJECTIVES: Coagulopathy is a potential complication of head trauma that may be attributable to parenchymal brain damage. The objectives of this study were to assess the frequency of coagulation defects in pediatric abusive head trauma and to analyze their relationship to parenchymal brain damage. METHODS: We reviewed the records of 265 pediatric patients hospitalized for head trauma. One hundred forty-seven patients met study inclusion criteria: (1) radiologic evidence of head trauma, (2) multidisciplinary validation that head trauma had been inflicted, and (3) coagulation screening performed within 2 days of presentation. Using nonparametric analysis, initial coagulation test results were compared between study patients without parenchymal brain damage and those with parenchymal brain damage. RESULTS: Mild prothrombin time (PT) prolongations (median 13.1) occurred in 54% of study patients with parenchymal brain damage and only 20% of study patients without parenchymal brain damage. Among pediatric abusive head trauma patients with parenchymal brain damage who died, 94% displayed PT prolongations (median 16.3) and 63% manifested evidence of activated coagulation. CONCLUSIONS: PT prolongation and activated coagulation are common complications of pediatric abusive head trauma. In the presence of parenchymal brain damage, it is highly unlikely that these coagulation abnormalities reflect a preexisting hemorrhagic diathesis. These conclusions have diagnostic, prognostic, and legal significance.

Child sexual abuse.

Multiple obstacles can hinder the medical evaluation of suspected child sexual abuse in pediatric primary care. The need for diagnostic accuracy is high. Knowledge of sexual abuse risk factors, an understanding of the victimization process, and awareness of the varied clinical presentations of sexual abuse can be of assistance. Open-ended questioning of the suspected victim is the most critical component of the evaluation. Skillful medical interviewing requires time, training, patience, and practice. Pediatricians lacking any of these four requirements should defer interviewing in sexual abuse cases to other professionals. Abnormal physical findings from sexual abuse are uncommon. Colposcopy has assisted pediatricians greatly in reaching consensus regarding diagnostic physical findings. Cases of acute sexual assault require familiarity with the forensic rape examination, STD screening and prophylaxis, and pregnancy prevention. Victimization from sexual abuse continues long after the abusive acts end, often requiring long-term therapeutic intervention. An emerging standard of care for medical evaluations of suspected child sexual abuse recognizes the requirement for patience and compassion while retaining objectivity. The pediatrician's primary concern must be for the child's physical and emotional well-being.