Jonathan D. Thackeray

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.

Mortality increases with recurrent episodes of nonaccidental trauma in children

BACKGROUND Nonaccidental trauma (NAT) is a leading cause of childhood traumatic injury and death. Our objectives were to compare the mortality rates of children who experience recurrent episodes of NAT (rNAT) with children who experience a single episode of NAT and to identify factors associated with rNAT and increased mortality from rNAT. METHODS Patients of NAT and rNAT in the Ohio State Trauma Registry were identified by matching date of birth, race, and sex between records of patients younger than 16 years between 2000 and 2010 with an DRG International Classification of Diseases—9th Rev. e-code for child abuse (E967–E967.9). Statistical comparisons were made using Fisher’s exact and Wilcoxon rank-sum tests. RESULTS A total of 1,572 patients of NAT were identified, with 53 patients meeting criteria for rNAT. Compared with patients with single-episode NAT, patients with rNAT were more commonly male (66% vs. 52%, p = 0.05), were white (83% vs. 65%, p = 0.02), were evaluated at a pediatric trauma center (87% vs. 69%, p = 0.008), and had higher mortality (24.5% vs. 9.9%, p = 0.002). Compared with rNAT patients who did not die, those who died with rNAT had a longer interval from initial episode to second episode (median [interquartile range], 527 days [83–1,099] vs. 166 days [52–502]; p = 0.07) and were older during their second episode (1 year [<6 months to 3 years] vs. <6 months [<6 months to 1 year]; p = 0.06). At initial presentation, lower-extremity fractures (p = 0.09) and liver injuries (p = 0.06) were reported more commonly in nonsurvivors of rNAT. CONCLUSION Mortality is significantly higher in children who experience rNAT. Therefore, it is critically important to effectively intervene with appropriate resources and follow-up after a child’s initial episode of NAT to prevent a future catastrophic episode. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level IV.

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 childs 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.

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.

Pediatric sexual assault nurse examiner care: Trace forensic evidence, ano-genital injury, and judicial outcomes

Introduction: Although pediatric sexual assault nurse examiners (P‐SANEs) have been providing care for over two decades there remain major gaps in the literature describing the quality of P‐SANE care and legal outcomes associated with their cases. The purpose of this study was to compare quality indicators of care in a pediatric emergency department (PED) before and after the implementation of a P‐SANE program described in terms of trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault. Method: A retrospective review of medical and legal records of all patients presenting to the PED at Nationwide Childrens Hospital with concerns of acute sexual abuse/assault requiring forensic evidence collection from 1/1/04 to 12/31/07 was conducted. Findings: Detection and documentation of ano‐genital injury, evaluation and documentation of pregnancy status, and testing for N. gonorrhea and C. trachomatis was significantly improved since implementation of the P‐SANE Program compared to the historical control. Discussion: The addition of a P‐SANE to the emergency department (ED) provider team improved the quality of care to child/adolescent victims of acute sexual abuse/assault.

Clinical Report—Intimate Partner Violence: The Role of the Pediatrician

The American Academy of Pediatrics and its members recognize the importance of improving the physicians 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.American Academy of Pediatrics and its members recognize the importance of improving the physicians 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. Pediatri- cians 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. Pediatrics 2010;125:1094-1100

Clinical report - Intimate partner violence

The American Academy of Pediatrics and its members recognize the importance of improving the physicians 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.American Academy of Pediatrics and its members recognize the importance of improving the physicians 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. Pediatri- cians 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. Pediatrics 2010;125:1094-1100