Timely Recognition of Abusive Injuries (TRAIN): Results from a Statewide Quality Improvement Collaborative.

Early recognition of physical abuse is critical as children often experience recurrent abuse if their environment remains unchanged. The Timely Recognition of Abusive Injuries (TRAIN) Collaborative was a quality improvement network of 6 Ohio children's hospitals created in 2015 to improve the management of injuries concerning for abuse in infants. TRAIN's first phase sought to reduce recurrent abuse by recognizing and responding to injured infants. This study aimed to reduce reinjury rate among infants ≤6 months by 10% at 1 year and 50% by 2 years and sustain improvement for 1 year as reflected in 3- and 12-month reinjury rates. Methods: The TRAIN Collaborative adopted the Institute for Healthcare Improvement's Breakthrough Series Collaborative Model, where partnerships between organizations facilitate learning from each other and experts. Collaborative members identified opportunities to improve injury recognition, implemented changes, responded to data, and reconvened to share successes and obstacles. As a result, institutions implemented different interventions, including education for clinical staff, increased social work involvement, and scripting for providers. Results: Data collected over 3 years were compared to a 12-month baseline. The number of injuries increased from 51 children with concerning injuries identified monthly to 76 children sustained throughout the collaborative. However, within 2 years, the 3- and 12-month reinjury rates ultimately significantly decreased from 5.7% to 2.1% and 6.5% to 3.7%, respectively. Conclusion: Our data suggest the Institute for Healthcare Improvement's Breakthrough Series model can be applied across large populations to improve secondary injury prevention in infants.

Identification of Initial and Subsequent Injury in Young Infants: Opportunities for Quality Improvement in the Evaluation of Child Abuse.

METHODS: Six children's hospitals identified infants with an initial injury and recurrent injury over a 1-year period using 2 methods: (1) diagnostic code method - infants 6 months or younger presenting with at least 1 diagnostic code for injury were tracked for 12 months to determine the frequency of recurrent injury, and (2) consult method - all available medical records of children 18 months or younger seen for an inpatient consultation for suspected child abuse were reviewed to identify history of a first injury at 6 months or younger. RESULTS: Using the diagnostic code method, 682 unique infants were identified with initial injuries, most commonly fractures (37.0%), bruising/ecchymosis (35.9%), and superficial injuries (28.3%). Forty-two infants (6.2%) returned with a second injury, and no demographic factors were significantly associated with the likelihood of a second injury. Using the consult method, 37 of 342 consults (10.8%) were identified as having a history of at least 1 initial injury. Of the initial injuries identified, the most common was bruising/ecchymosis (64.9%). The number of injuries identified with either method varied significantly across hospitals, as did completion of skeletal surveys for infants with bruising (range, 4.5%-71.1%; P < 0.001) and any injury (range, 4.4%-62.7%; P < 0.001). CONCLUSIONS: Our study demonstrates that young infants who experience 1 injury often experience a second injury. There exists significant variability in the identification of injury and the completion of skeletal surveys across a network of 6 children's hospitals. A standardized quality improvement approach may improve identification of injury and reduce the variability in practice observed.

Occult Injury Screening Among Infants With Subconjunctival Hemorrhage.

PURPOSE: To assess the frequency and nature of occult injury screening in infants with subconjunctival hemorrhages (SCH), the incidence of occult injuries in these children, and the factors that may have influenced the decision to screen for additional injury. METHODS: Infants aged 14 days to 6 months with SCH who presented to two tertiary pediatric centers were identified from a local database (N = 84). A retrospective chart review collected demographics, examination findings, and imaging results. Infants were further stratified into two groups depending on the presence of additional mucocutaneous injuries. The groups were compared with two-sample t testing. RESULTS: Skeletal surveys were completed in 31% of patients overall, but the rate of screening was significantly higher among patients who presented with SCH and additional mucocutaneous injuries as opposed to SCH alone. However, the presence of additional mucocutaneous injuries was not associated with an increased risk for positive skeletal survey. CONCLUSIONS: Rates of occult injury screening among infants with SCH were low and were significantly influenced by the presence of additional injuries. When screening was conducted, occult injuries were commonly identified. Future studies should assess the true prevalence of abuse in this population. [J Pediatr Ophthalmol Strabismus. 2021;58(4):213-217.].

Discrepancies in Physician and Coroner Findings in Cases of Fatal Suspected Physical Child Abuse.

OBJECTIVES: As mandated reporters of suspected abuse, physicians must consider abuse when a child dies unexpectedly. Subsequently, a coroner or medical examiner determines the manner of death (MOD) and cause of death (COD). Accurate diagnoses and determinations are important for social safety and justice. This study described discrepancies between physicians' and coroners' findings in cases of fatal suspected physical child abuse. METHODS: This study was a single-institution, retrospective review. All children 6 years or younger who died in a pediatric emergency department from October 2006 to January 2013 with a coroner report were included in this study. Coroner reports, MODs, and CODs were reviewed. Skeletal survey results were compared with coroners' findings. RESULTS: One hundred twenty-nine children were included. The MODs included the following: undetermined, 63 (49%); accident, 32 (25%); natural, 31 (24%); and homicide, 3 (2%). Thirty-three (26%) of the 129 patients had abuse suspected at the time of death in the emergency department; in this subset, MODs were as follows: undetermined, 16 (48%); accident, 8 (24%); natural, 6 (18%); and homicide, 3 (9%). Sudden infant death syndrome or sudden unexpected death was the most common COD in all children (68, 55%). Skeletal surveys were positive in 12 children with 29 fractures identified; 8 (28%) of the 29 fractures were corroborated on autopsy findings. Of the 12 children with positive skeletal survey findings, only 1 was ruled a homicide. CONCLUSIONS: We found discrepancies between coroner determination of homicide and abuse suspected by physicians, especially among children with fractures. Improved communication between agencies in cases of fatal child abuse is needed.

Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition.

OBJECTIVES: To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS: Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS: Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS: About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.

A national survey on the use of screening tools to detect physical child abuse.

PURPOSE: Recognition of physical child abuse is imperative for ensuring children's safety. Screening tools (ST) may increase identification of physical abuse; however, the extent of their use is unknown. This study assessed use of STs for physical abuse in children's hospitals and determined attitudes regarding STs. METHODS: A web-based survey was sent to child abuse program contacts at 103 children's hospitals. The survey assessed institutional use of a ST for physical abuse and characteristics of the ST used. Respondents were asked to identify benefits and liabilities of STs used or barriers to ST use. RESULTS: Seventy-two respondents (70 %) completed the survey; most (64 %) were child abuse pediatricians. Nine (13 %) respondents reported using a ST for physical abuse; STs varied in length, population, administration, and outcomes of a positive screen. Most respondents (86 %) using a ST felt that it increased detection of abuse. Barriers noted included lack of time for development and provider completion of a ST. CONCLUSIONS: While few respondents endorsed use of a ST for physical abuse, most believed that it increased detection of abuse. Future research should focus on development of a brief, uniform ST for physical abuse which may increase detection in at-risk children.

The classic metaphyseal lesion and traumatic injury.

BACKGROUND: It is widely accepted that the classic metaphyseal lesion (CML) is a traumatic lesion, strongly associated with abuse in infants. Nevertheless, various non-traumatic origins for CMLs continue to be suggested in medical and legal settings. No studies to date systematically describe the association of CMLs with other traumatic injuries. OBJECTIVE: The primary objective of this study is to examine the association of CMLs with other traumatic injuries in a large data set of children evaluated for physical abuse. MATERIALS AND METHODS: This was a retrospectively planned secondary analysis of data from a prospective, observational study of children <120 months of age who underwent evaluation by a child abuse physician. For this secondary analysis, we identified all children ≤12 months of age with an identified CML and determined the number and type of additional injuries identified. Descriptive analysis was used to report frequency of additional traumatic injuries. RESULTS: Among 2,890 subjects, 119 (4.1%) were identified as having a CML. Of these, 100 (84.0%) had at least one additional (non-CML) fracture. Thirty-three (27.7%) had traumatic brain injury. Nearly half (43.7%) of children had cutaneous injuries. Oropharyngeal injuries were found in 12 (10.1%) children. Abdominal/thoracic injuries were also found in 12 (10.1%) children. In all, 95.8% of children with a CML had at least one additional injury; one in four children had three or more categories of injury. CONCLUSION: CMLs identified in young children are strongly associated with traumatic injuries. Identification of a CML in a young child should prompt a thorough evaluation for physical abuse.

Neurological Manifestations of Medical Child Abuse.

BACKGROUND: Medical child abuse occurs when a child receives unnecessary and harmful, or potentially harmful, medical care at the instigation of a caretaker through exaggeration, falsification, or induction of symptoms of illness in a child. Neurological manifestations are common with this type of maltreatment. OBJECTIVES: We sought to review common reported neurological manifestations that may alert the clinician to consider medical child abuse. In addition, the possible sequelae of this form of child maltreatment is discussed, as well as practice recommendations for establishing the diagnosis and stopping the abuse once it is identified. METHODS: A review of the medical literature was conducted regarding the reported neurological presentations of this entity. RESULTS: Neurological manifestations of medical child abuse include false reports of apparent life-threatening events and seizures and reports of induction of symptoms from poisoning. Failure to correlate objective findings with subjective complaints may lead to unnecessary and potentially harmful testing or treatment. This form of child maltreatment puts a child at significant risk of long-term morbidity and mortality. CONCLUSIONS: A wide variety of neurological manifestations have been reported in cases of medical child abuse. It is important for the practicing neurologist to include medical child abuse on the differential diagnosis.

Child advocacy center multidisciplinary team decision and its association to child protective services outcomes.

Limited studies exist evaluating the multidisciplinary team (MDT) decision-making process and its outcomes. This study evaluates the MDT determination of the likelihood of child sexual abuse (CSA) and its association to the outcome of the child protective services (CPS) disposition. A retrospective cohort study of CSA patients was conducted. The MDT utilized an a priori Likert rating scale to determine the likelihood of abuse. Subjects were dichotomized into high versus low/intermediate likelihood of CSA as determined by the MDT. Clinical and demographic characteristics were compared based upon MDT and CPS decisions. Fourteen hundred twenty-two patients were identified. A high likelihood for abuse was determined in 997 cases (70%). CPS substantiated or indicated the allegation of CSA in 789 cases (79%, Kappa 0.54). Any CSA disclosure, particularly moderate risk disclosure (AOR 59.3, 95% CI 26.50-132.80) or increasing total number of CSA disclosures (AOR 1.3, 95% CI 1.11-1.57), was independently associated with a high likelihood for abuse determination. Specific clinical features associated with discordant cases in which MDT determined high likelihood for abuse and CPS did not substantiate or indicate CSA included being white or providing a low risk CSA disclosure or other non-CSA disclosure. MDT determination regarding likelihood of abuse demonstrated moderate agreement to CPS disposition outcome. CSA disclosure is predictive of the MDT determination for high likelihood of CSA. Agreement between MDT determination and CPS protection decisions appear to be driven by the type of disclosures, highlighting the importance of the forensic interview in ensuring appropriate child protection plans.

Dedicated retinal examination in children evaluated for physical abuse without radiographically identified traumatic brain injury.

OBJECTIVE: To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging. STUDY DESIGN: This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI. RESULTS: The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification. CONCLUSIONS: Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination.

Forensic evidence collection and DNA identification in acute child sexual assault.

OBJECTIVE: To describe forensic evidence findings and reevaluate previous recommendations with respect to timing of evidence collection in acute child sexual assault and to identify factors associated with yield of DNA. METHODS: This was a retrospective review of medical and legal records of patients aged 0 to 20 years who required forensic evidence collection. RESULTS: Ninety-seven of 388 (25%) processed evidence-collection kits were positive and 63 (65%) of them produced identifiable DNA. There were 20 positive samples obtained from children younger than 10 years; 17 of these samples were obtained from children seen within 24 hours of the assault. Three children had positive body samples beyond 24 hours after the assault, including 1 child positive for salivary amylase in the underwear and on the thighs 54 hours after the assault. DNA was found in 11 children aged younger than 10 years, including the child seen 54 hours after the assault. Collection of evidence within 24 hours of the assault was identified as an independent predictor of DNA detection. CONCLUSIONS: Identifiable DNA was collected from a child's body despite cases in which: evidence collection was performed >24 hours beyond the assault; the child had a normal/nonacute anogenital examination; there was no reported history of ejaculation; and the victim had bathed and/or changed clothes before evidence collection. Failure to conduct evidence collection on prepubertal children beyond 24 hours after the assault will result in rare missed opportunities to identify forensic evidence, including identification of DNA.

Yield of retinal examination in suspected physical abuse with normal neuroimaging.

OBJECTIVE: In some centers, dedicated ophthalmologic examination is performed for all children who are evaluated for potential physical abuse. Although retinal hemorrhages have been reported in rare cases of abused children with normal neuroimaging results, the utility of ophthalmologic examination in this group is currently unknown. The objective of this study was to determine the prevalence of retinal hemorrhages in children younger than 2 years who were evaluated for physical abuse and who had no evidence of traumatic brain injury (TBI) on neuroimaging. PATIENTS AND METHODS: We performed retrospective analysis of data obtained from 1676 children younger than 5 years who were evaluated for potential physical abuse as a part of the Using Liver Transaminases to Recognize Abuse research network. We reviewed results of dedicated ophthalmologic examination in all children younger than 2 years with no evidence of TBI on neuroimaging. RESULTS: Among 282 children who met inclusion criteria, only 2 (0.7% [95% confidence interval: 0.1%-2.5%]) had retinal hemorrhages considered "characteristic" of abuse. Seven other children (2.5% [95% confidence interval: 1.0%-5.1%]) had a nonspecific pattern of retinal hemorrhages. Both children with characteristic retinal hemorrhages in the absence of TBI showed evidence of head or facial injury on physical examination and/or altered mental status. CONCLUSIONS: In children younger than 2 years being evaluated for physical abuse without radiographic evidence of brain injury, retinal hemorrhages are rare. Dedicated ophthalmologic examination should not be considered mandatory in this population.

Intimate partner violence: the role of the pediatrician.

The American Academy of Pediatrics and its members recognize the importance of improving the physician's ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children.

Seasonality of child homicide.

OBJECTIVE: To determine whether there is seasonal variation (by season and month of year) in homicides among young children. STUDY DESIGN: Homicide deaths in children

Domestic violence assessments in the child advocacy center.

OBJECTIVE: This study was designed to identify the frequency, methods, and practices of universal assessments for domestic violence (DV) within child advocacy centers (CACs) and determine which factors are associated with CACs that conduct universal DV assessments. METHODS: The study design was a cross-sectional, web-based survey distributed to executive directors of National Children's Alliance accredited or accreditation-eligible CACs. RESULTS: Responses were received from 323 of 376 eligible CACs (86%). Twenty-nine percent of CAC directors report familiarity with current DV recommendations and 29% require annual education for staff regarding DV. Twenty-nine percent of CACs conduct "universal assessments" (defined as a CAC that assesses female caregivers for DV more than 75% of the time). The majority of CACs use face-to-face interviews to conduct assessments, often with children, family or friends present. The presence of on-site DV resources (OR=2.85, CI 1.25-6.50) and an annual DV educational requirement (OR=2.88, CI 1.31-6.32) are associated with assessment of female caregivers. The presence of on-site DV resources (OR=3.97, CI 2.21-7.14) is associated with universal assessments. CONCLUSIONS: Many CAC directors are not aware of current DV recommendations and do not require annual DV training for staff. Less than one-third of CACs practice universal assessments and those that do often conduct DV assessments with methods and environments shown to be less comforting for the patient and less effective in victim identification. CACs are more likely to assess female caregivers if they have co-located DV resources and they require DV training of their staff. CACs are more likely to universally screen for DV if they have co-located DV resources. PRACTICE IMPLICATIONS: The presence of DV in the home has significant potential to negatively impact a child's physical and mental health as well as the ability of the caregiver to adequately protect the child. Current practice in CACs suggests a knowledge gap in this area and this study identifies an opportunity to improve the services offered to these high-risk families.

Has this prepubertal girl been sexually abused?

CONTEXT: The legal and social sequelae of interpreting genital findings as indicative of sexual abuse are significant. While the absence of genital trauma does not rule out sexual abuse, the physical examination can identify genital findings compatible with sexual abuse. OBJECTIVES: To determine the diagnostic utility of the genital examination in prepubertal girls for identifying nonacute sexual abuse. DATA SOURCES: Published articles (1966-October 2008) that appeared in the MEDLINE database and were indexed under the search terms of child abuse, sexual or child abuse and either physical examination; genitalia; female, diagnosis; or sensitivity and specificity; and bibliographies of retrieved articles and textbooks. STUDY SELECTION: Three of the authors independently reviewed titles of articles obtained from MEDLINE and selected articles for full-text review. DATA EXTRACTION: Two authors independently abstracted data to calculate sensitivity, specificity, and likelihood ratios for the diagnosis of nonacute genital trauma caused by sexual abuse in prepubertal girls. RESULTS: Data were not pooled due to study heterogeneity. The presence of vaginal discharge (positive likelihood ratio, 2.7; 95% confidence interval, 1.2-6.0) indicates an increased likelihood of sexual abuse. In the posterior hymen, hymenal transections, deep notches, and perforations prompt concerns for genital trauma from sexual abuse, but the sensitivity is unknown. Without a history of genital trauma from sexual abuse, the majority of prepubertal girls will not have a hymenal transection (specificity close to 100%). CONCLUSIONS: Vaginal discharge as well as posterior hymenal transections, deep notches, and perforations raise the suspicion for sexual abuse in a prepubertal girl, but the findings do not independently confirm the diagnosis. Given the broad 95% confidence intervals around the likelihood ratios for the presence of findings along with the low or unknown sensitivity of all physical examination findings evaluated, the physical examination cannot independently confirm or exclude nonacute sexual abuse as the cause of genital trauma in prepubertal girls.