Joanne N. Wood

Disparities in the Evaluation and Diagnosis of Abuse Among Infants With Traumatic Brain Injury

OBJECTIVE: To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants. METHODS: We conducted a retrospective study of infants with non–motor vehicle–associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities. RESULTS: After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P = .022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P = .009). CONCLUSIONS: National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured).

Local Macroeconomic Trends and Hospital Admissions for Child Abuse, 2000–2009

OBJECTIVE: To examine the relationship between local macroeconomic indicators and physical abuse admission rates to pediatric hospitals over time. METHODS: Retrospective study of children admitted to 38 hospitals in the Pediatric Hospital Information System database. Hospital data were linked to unemployment, mortgage delinquency, and foreclosure data for the associated metropolitan statistical areas. Primary outcomes were admission rates for (1) physical abuse in children <6 years old, (2) non-birth, non-motor vehicle crash-related traumatic brain injury (TBI) in infants <1 year old (which carry high risk for abuse), and (3) all-cause injuries. Poisson fixed-effects regression estimated trends in admission rates and associations between those rates and trends in unemployment, mortgage delinquency, and foreclosure. RESULTS: Between 2000 and 2009, rates of physical abuse and high-risk TBI admissions increased by 0.79% and 3.1% per year, respectively (P ≤ .02), whereas all-cause injury rates declined by 0.80% per year (P < .001). Abuse and high-risk TBI admission rates were associated with the current mortgage delinquency rate and with the change in delinquency and foreclosure rates from the previous year (P ≤ .03). Neither abuse nor high-risk TBI rates were associated with the current unemployment rate. The all-cause injury rate was negatively associated with unemployment, delinquency, and foreclosure rates (P ≤ .007). CONCLUSIONS: Multicenter hospital data show an increase in pediatric admissions for physical abuse and high-risk TBI during a time of declining all-cause injury rate. Abuse and high-risk TBI admission rates increased in relationship to local mortgage delinquency and foreclosure trends.

Vitamin D Status in Abused and Nonabused Children Younger Than 2 Years Old With Fractures

OBJECTIVE: To examine vitamin D levels in children with (1) suspected abusive and accidental fractures, (2) single and multiple fractures, and (3) fracture types highly associated with inflicted trauma. DESIGN AND METHODS: A study of children younger than 2 years of age with fractures admitted to a large childrens hospital was performed. Bivariate analysis and test for trend were performed to test for the association of vitamin D status and biochemical markers of bone health with the primary outcomes of fracture etiology, number, and type. RESULTS: Of 118 subjects in the study, 8% had deficient vitamin D levels (<20 ng/mL; <50 nmol/L), 31% were insufficient (≥20 < 30 ng/mL; ≥50 < 78 nmol/L), and 61% were sufficient (≥30 ng/mL; ≥78 nmol/L). Lower vitamin D levels were associated with higher incidences of hypocalcemia (P = .002) and elevated alkaline phosphatase (P = .05) but not hypophosphatemia (P = .30). The majority of children sustained accidental fractures (60%); 31% were nonaccidental and 9% were indeterminate. There was no association between vitamin D levels and any of the following outcomes: child abuse diagnosis (P = .32), multiple fractures (P = .24), rib fractures (P = .16), or metaphyseal fractures (P = .49). CONCLUSIONS: Vitamin D insufficiency was common in young children with fractures but was not more common than in previously studied healthy children. Vitamin D insufficiency was not associated with multiple fractures or diagnosis of child abuse. Nonaccidental trauma remains the most common cause of multiple fractures in young children.

Skeletal surveys in infants with isolated skull fractures.

OBJECTIVE. The goal was to describe the utility of skeletal surveys and factors associated with both skeletal survey use and referral to child protective services for infants with skull fractures in the absence of significant intracranial injury. METHODS. A retrospective chart review was performed for infants who were evaluated at a tertiary childrens hospital because of an isolated, non–motor vehicle-related, skull fracture between 1997 and 2006. Logistic regression analyses were used to test for associations of demographic factors, clinical findings that raised suspicion for abuse (absence of trauma history, changing history, delay in care, previous child protective services involvement, and other cutaneous injuries), and fracture type (simple versus complex) with the primary outcomes of skeletal survey use and reports to child protective services. RESULTS. Among the 341 infants in the study, 31% had clinical findings that raised suspicion for abuse and 42% had complex skull fractures. Skeletal surveys were obtained for 141 infants (41%) and detected additional fractures for only 2 (1.4%) of those 141 infants. Child protective services reports were made for 52 (15%) of the 341 children. Both infants with positive skeletal survey findings had other clinical findings that raised suspicion for abuse, and they were among those reported. With controlling for race and age, Medicaid-eligible/uninsured infants were more likely than privately insured infants to receive skeletal surveys and child protective services reports in the presence of a complex skull fracture or clinical findings that raised suspicion for abuse. CONCLUSION. Skeletal surveys were ordered frequently for infants with isolated skull fractures, but they rarely added additional information, beyond the history and physical findings, to support a report to child protective services.

Variation in Occult Injury Screening for Children With Suspected Abuse in Selected US Children’s Hospitals

OBJECTIVE: To describe variation across selected US children’s hospitals in screening for occult fractures in children <2 years old diagnosed with physical abuse and in infants <1 year old who have injuries associated with a high likelihood of physical abuse. METHODS: We performed a retrospective study of children <2 years old with a diagnosis of physical abuse and infants <1 year old with non-motor vehicle crash–associated traumatic brain injuries or femur fractures admitted to 40 hospitals within the Pediatric Hospital Information System database from January 1, 1999, to December 31, 2009. We examined variation among the hospitals in the performance of screening for occult fractures as defined by receipt of skeletal survey or radionuclide bone scan. Marginal standardization implemented with logistic regression analysis was used to examine hospital variation after adjusting for patient demographic characteristics, injury severity, and year of admission. RESULTS: Screening for occult fractures was performed in 83% of the 10 170 children <2 years old with a diagnosis of physical abuse, 68% of the 9942 infants who had a traumatic brain injury, and 77% of the 2975 infants who had femur fractures. After adjustment for patient characteristics, injury severity, and year of admission, hospitals varied significantly in use of screening for occult fractures in all 3 groups of children. CONCLUSIONS: The observed variation in screening for occult fractures in young victims of physical abuse and infants who have injuries associated with a high likelihood of abuse underscores opportunities to improve the quality of care provided to this vulnerable population.

Development of Guidelines for Skeletal Survey in Young Children With Fractures

OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS: Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists rerated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary. RESULTS: Panelists agreed that SS is “appropriate” for 191 (80%) of 240 scenarios rated and “necessary” for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. CONCLUSIONS: A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.

Subdural hemorrhage in pediatric patients with enlargement of the subarachnoid spaces

OBJECT Enlargement of the subarachnoid spaces has been theorized as a risk factor for the development of subdural hemorrhage (SDH). As the finding of unexplained SDH in children often raises suspicion for nonaccidental trauma, the possibility of increased risk of SDH in children with enlargement of the subarachnoid spaces has important clinical, social, and legal implications. Therefore, the authors evaluated the frequency of SDH in a cohort of children with enlargement of the subarachnoid spaces. METHODS The authors identified children younger than 2 years of age who were diagnosed with enlargement of the subarachnoid spaces on MRI or CT scanning in a large primary care network between July 2001 and January 2008. The authors excluded children who had enlargement of the subarachnoid spaces diagnosed on imaging performed for trauma or developmental delay, as well as children with a history of prematurity, diagnosis of intracranial pathology, or metabolic or genetic disorders. Chart review recovered the following data: patient demographics, head circumference, history of head trauma, and head imaging results. For the subset of children with SDH, information regarding evaluation for other injuries, including skeletal survey, ophthalmological examination, and child protection team evaluation, was abstracted. RESULTS There were 177 children with enlargement of the subarachnoid spaces who met the inclusion criteria. Subdural hemorrhage was identified in 4 (2.3%) of the 177 children. All of the children with SDH underwent evaluations for suspected nonaccidental trauma, which included consultation by the child protection team, skeletal survey, and ophthalmological examination. Additional injuries (healing rib fractures) were identified in 1 of 4 patients. None of the 4 children had retinal hemorrhages. Only the child with rib fractures was reported to child protective services due to concerns for abuse. CONCLUSIONS Only a small minority of the patients with enlargement of the subarachnoid spaces had SDH. Evidence of additional injuries concerning for physical abuse were identified in a quarter of the children with enlargement of the subarachnoid spaces and SDH, suggesting that an evaluation for suspected nonaccidental trauma including occult injury screening should be performed in cases of SDH with enlargement of the subarachnoid spaces. In the absence of additional injuries, however, the presence of an unexplained SDH in the setting of enlargement of the subarachnoid spaces may be insufficient to support a diagnosis of nonaccidental trauma.

Testing for abuse in children with sentinel injuries

OBJECTIVE: Child physical abuse is commonly missed, putting abused children at risk for repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children’s hospitals with these putative sentinel injuries. METHODS: This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries. RESULTS: Among all visits for children <24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children <12 months old with burns to 56.1% for children <24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries. CONCLUSIONS: Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.

Evaluation for Occult Fractures in Injured Children

OBJECTIVES: To examine variation across US hospitals in evaluation for occult fractures in (1) children <2 years old diagnosed with physical abuse and (2) infants <1 year old with injuries associated with a high likelihood of abuse and to identify factors associated with such variation. METHODS: We performed a retrospective study in children <2 years old with a diagnosis of physical abuse and in infants <1 year old with non-motor vehicle crash–related traumatic brain injury or femur fractures discharged from 366 hospitals in the Premier database from 2009 to 2013. We examined across-hospital variation and identified child- and hospital-level factors associated with evaluation for occult fractures. RESULTS: Evaluations for occult fractures were performed in 48% of the 2502 children with an abuse diagnosis, in 51% of the 1574 infants with traumatic brain injury, and in 53% of the 859 infants with femur fractures. Hospitals varied substantially with regard to their rates of evaluation for occult fractures in all 3 groups. Occult fracture evaluations were more likely to be performed at teaching hospitals than at nonteaching hospitals (all P < .001). The hospital-level annual volume of young, injured children was associated with the probability of occult fracture evaluation, such that hospitals treating more young, injured patients were more likely to evaluate for occult fractures (all P < .001). CONCLUSIONS: Substantial variation in evaluation for occult fractures among young children with a diagnosis of abuse or injuries associated with a high likelihood of abuse highlights opportunities for quality improvement in this vulnerable population.

Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises

OBJECTIVE: To develop guidelines for performing an initial skeletal survey (SS) for children <24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion. METHODS: Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children <24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS. RESULTS: Panelists agreed that SS is “appropriate” for 62% (136/219) of scenarios, and “inappropriate” for children ≥12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is “necessary” for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants <6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children <12 months. CONCLUSIONS: The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising.