Alice W. Newton

Skeletal Trauma in Child Abuse: Detection with 18F-NaF PET

PURPOSEnTo 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.nnnMATERIALS AND METHODSnThe 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.nnnRESULTSnA 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.nnnCONCLUSIONn(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.

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

OBJECTIVEnThe 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.nnnMATERIALS AND METHODSnThis 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.nnnRESULTSnThere 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%).nnnCONCLUSIONnClassic 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 Munchausen syndrome by proxy

Purpose of review Munchausen syndrome by proxy (MBP) is a complicated form of child maltreatment. Difficulties remain in properly defining the condition, as well as in detection and differentiation from organic illness. This review will discuss the epidemiology and diagnosis of MBP, as well as the role of the physician in sorting out these cases. Recent findings Several recent case studies, including two in which children were diagnosed with celiac disease, add to our knowledge of the protean manifestations of MBP. There is growth in our understanding of how sudden infant death syndrome (SIDS) and the symptom complex seen in acute life-threatening events (ALTEs) may in fact represent manifestations of MBP. Recent legal issues in the United Kingdom pose concern for all physicians engaged in child protection work. Summary In spite of these challenges, the high mortality and recidivism rates associated with MBP make it imperative that pediatricians be familiar with the condition, the subtle signs and symptoms with which it may present, and methods to best protect the children in their care.

Whole-Body MRI in Suspected Infant Abuse

OBJECTIVEnThe 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.nnnMATERIALS AND METHODSnTwenty-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.nnnRESULTSnSummary 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.nnnCONCLUSIONnWB-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.

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 years 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.

Update on child maltreatment with a special focus on shaken baby syndrome.

Purpose of review The many forms of child maltreatment exact an unacceptably heavy toll on our children. Recent work exploring the risk factors for child abuse and neglect, long-term consequences of child maltreatment, and potential for primary prevention will be reviewed. In the past year there have been many notable contributions in the field of shaken baby syndrome that have deepened our understanding of this devastating form of child abuse. Recent findings Evidence of the long-term sequelae of child abuse and neglect continues to accumulate, but with increased understanding of the clinical manifestations of child maltreatment has come greater ability to intervene early and perhaps improve long-term outcomes. Although the effectiveness of some home visiting programs to prevent child maltreatment is coming into question, rigorous review of program components is helping to improve quality. There remain controversies in the diagnosis of shaken baby syndrome but several carefully done case-series are clarifying our knowledge of the myriad presentations of this form of non-accidental head trauma. Summary Pediatricians have an important role to play in the prevention and recognition of child maltreatment.

Unexplained infant and child death: a review of Sudden Infant Death Syndrome, Sudden Unexplained Infant Death, and child maltreatment fatalities including shaken baby syndrome

Purpose of review This review will examine the most recent published literature on Sudden Infant Death, Sudden Unexplained Infant Death, infant and child death due to maltreatment, and Shaken Baby Syndrome. Recent findings New recommendations from the American Academy of Pediatrics about the evaluation and prevention of possible Sudden Infant Death Syndrome cases were published this year, with a focus not only on the Back to Sleep campaign, but other factors that may contribute to the risk of Sudden Infant Death Syndrome. Additionally, the controversial issue of bed sharing is addressed, with advice given not to bed share in the first 3 months of life. The possibility of a second sudden infant death within a family is discussed. Attention is also paid to the importance of considering inflicted injury in the differential diagnosis of every unexplained infant or child death, and the recent literature on child maltreatment deaths is reviewed. Summary The grieving family who has lost an infant should receive immediate attention and support, and a multidisciplinary investigation team should be involved as soon as possible so that a full investigation can take place. Investigation of unexplained infant or child death should always involve a thorough interview with all adults involved, as well as a proper scene investigation and post-mortem examination.

Carbohydrate moieties of the basal lamina: their role in attachment and spreading of basal corneal epithelial cells

SummaryThree lectins, Wheat germ agglutinin, succinyl Concanavalin A and Ricinus communis agglutinin were used to block specific sugar moieties in the basal lamina. Corneal epithelial basal cells were plated onto freshly denuded basal lamina. Attachment was studied by quantifying the adherence of prelabeled cells and by examining attachment sites using transmission electron microscopy. Spreading was examined using scanning electron microscopy. Attachment of the cells occurred within 15 min and spreading was apparent after 45 min. Both Wheat germ agglutinin and β-N-acetylglucosaminidase inhibited cellular attachment. Succinyl Concanavalin A and Ricinus Communis agglutinin permitted attachment, but inhibited extensive cellular spreading. The results indicate that the attachment of basal cells is dependent on N-acetylglucosamine residues, and spreading is mediated by alpha methylmannoside, glucose, and galactose residues.

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

BackgroundThe value of 3-D skull models in evaluation of young children with suspected child abuse is not known.ObjectiveThe purpose of this study was to assess the value of 3-D skull models as a problem-solving tool in children younger than 2xa0years.Materials and methodsWe performed a retrospective study on 73 children (ages 0–24xa0months) seen by a child protection team (CPT) who were undergoing head CT between August 2007 and July 2009.ResultsOf 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.ConclusionUse 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.

Inflicted T12 fracture-dislocation: CT/MRI correlation and mechanistic implications

We describe the CT and MRI findings of a thoracolumbar neurocentral synchondrosis fracture-dislocation in an abused infant. The morphologic features of this classically described fracture, and the associated cervical and sacral spine injuries displayed on cross-sectional imaging, provide compelling evidence for a mechanism of massive hyperflexion and axial spinal loading.