Kim Kaczor

Bruising characteristics discriminating physical child abuse from accidental trauma.

OBJECTIVE: Our objective was to conduct a pilot study to identify discriminating bruising characteristics and to model those findings into a decision tool for screening children at high risk for abuse. METHODS: A case-control study of children 0 to 48 months of age who were admitted to a PICU because of trauma was performed. Case subjects (N = 42) were victims of physical abuse, and control subjects (N = 53) were children admitted because of accidental trauma during the same time period. Bruising characteristics (total number and body region) and patient age were compared for children with abusive versus accidental trauma. The development of a decision rule for predicting abusive trauma was accomplished with the fitting of a classification and regression tree through binary recursive partitioning. RESULTS: Ninety-five patients were studied. Seventy-one (33 of 42 patients in the abuse group and 38 of 53 in the accident group) were found to have bruising, and the characteristics were modeled. Characteristics predictive of abuse were bruising on the torso, ear, or neck for a child ≤4 years of age and bruising in any region for an infant <4 months of age. A bruising clinical decision rule was derived, with a sensitivity of 97% and a specificity of 84% for predicting abuse. CONCLUSIONS: Discriminating differences exist in bruising characteristics for abusive versus accidental trauma. The body region- and age-based bruising clinical decision rule model functions as a clinically sensible screening tool to identify young children who require further evaluation for abuse.

Bruising in infants: those with a bruise may be abused.

Bruising in the young infant is rare, and if present, this may be a manifestation of physical child abuse. Early signs of abuse, such as bruising, are often overlooked or their significance goes unrecognized resulting in poor patient outcomes. In such cases, the opportunity to intervene and potentially prevent repeat injury is lost, and the child is placed back in harms way. This brief report presents 3 cases of nonmobile infants who presented to health care providers with bruising before a subsequent fatal or near-fatal event. These cases emphasize the importance of including abusive trauma in the differential diagnosis of an infant with a bruise or a history of easy bruising and the importance of initiating a thorough trauma evaluation immediately and concomitantly with any other workup for the causes of bruising in the noncruising infant.

Biomechanical investigation of the classic metaphyseal lesion using an immature porcine model.

OBJECTIVEnThe classic metaphyseal lesion is highly associated with abuse in infants. Classic metaphyseal lesions, also referred to as corner or bucket-handle fractures, are fractures through the metaphyseal region of the long bones near the growth plate. Knowledge of the biomechanics and mechanisms necessary to produce a classic metaphyseal lesion may provide insight into the injury causation associated with this unique fracture type. Thus, the purpose of this study was to investigate loading conditions necessary to create a classic metaphyseal lesion using an immature porcine model.nnnMATERIALS AND METHODSnTwenty-four pelvic limb specimens from 7-day-old and 3-day-old piglets were tested in lateral bending (varus and valgus) using an electromechanical testing machine. All specimens were loaded dynamically in four-point bending at a rate of 100 inches/min. Microcomputed tomography was performed on specimens before and after testing. Pre- and posttest CT images were compared to assess whether fracture had occurred.nnnRESULTSnFractures resembling classic metaphyseal lesions were identified in 12 of the 24 specimens. Microcomputed tomography images revealed trabecular disruptions visually similar to classic metaphyseal lesions in children.nnnCONCLUSIONnMetaphyseal fractures, consistent with clinical classic metaphyseal lesions, resulted from a single loading event delivering varus or valgus bending to the stifle (knee). A classic metaphyseal lesion is a unique type of fracture with specific morphologic characteristics. Therefore, we suggest using the term classic metaphyseal fracture in lieu of classic metaphyseal lesion to improve precision of terminology.

History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse

Failure to recognize child maltreatment results in chronic exposure to high-risk environments where re-injury or death may occur. We analyzed a series (n=20) of fatal (n=10) and near-fatal (n=10) physical child abuse cases from the Commonwealth of Kentucky to identify commonalities and determine whether indicators of maltreatment were present prior to the childs fatal or near-fatal event. We conducted retrospective state record reviews involving children <4years of age classified as physical child abuse by the Cabinet for Health and Family Services during a 12 month period. Cases were distributed across 17 counties. IRB approvals were obtained. Three reviewers concurrently abstracted case data from medical, social, and legal documents, and descriptive statistics were analyzed. Median age of subjects was 7.5 months (range 1-32 months); 55% were male. Psychosocial risk factors (PRFs) were present in 100% of cases. Traumatic brain injury (95%) and bruising (90%) were the most common injuries. Of the 14 children with available prior medical records, 9 (64%) had sentinel injuries in the form of prior unexplained bruising; all nine suffered subsequent traumatic brain injury resulting in four deaths. A male was caring for the child at the time of the final event in 70% of cases. Our study identified key commonalities across cases of fatal and near-fatal abuse, highlighting the prevalence of psychosocial risk factors and the significance of prior unexplained bruising as a herald of escalating abuse. Further study is warranted to ascertain the predictive value of our findings in the larger population.

Bringing Back the Social History

The social environment of a child is a key determinant of the childs current and future health. Factors in a childs family environment, both protective and harmful, have a profound impact on a childs long-term health, brain development, and mortality. The social history may be the best all-around tool available for promoting a childs future health and well-being. It is a key first step in identifying social needs of a child and family so that they may benefit from intervention. This article focuses on key social history elements known to increase a childs risk of maltreatment and provides case examples.

Is the Use of Physical Discipline Associated with Aggressive Behaviors in Young Children

OBJECTIVEnTo determine the association between use of physical discipline and parental report of physically aggressive child behaviors in a cohort of young children who were without indicators of current or past physical abuse.nnnMETHODSnThe data for this study were analyzed from an initial cohort of patients enrolled in a prospective, observational, multicenter pediatric emergency department-based study investigating bruising and familial psychosocial characteristics of children younger than 4 years of age. Over a 7-month period, structured parental interviews were conducted regarding disciplinary practices, reported child behaviors, and familial psychosocial risk factors. Children with suspected physical abuse were excluded from this study. Trained study staff collected data using standardized questions. Consistent with grounded theory, qualitative coding by 2 independent individuals was performed using domains rooted in the data. Inter-rater reliability of the coding process was evaluated using the kappa statistic. Descriptive statistics were calculated and multiple logistic regression modeling was performed.nnnRESULTSnThree hundred seventy-two parental interviews were conducted. Parents who reported using physical discipline were 2.8 (95% confidence interval [CI], 1.7-4.5) times more likely to report aggressive child behaviors of hitting/kicking and throwing. Physical discipline was used on 38% of children overall, and was 2.4 (95% CI, 1.4-4.1) times more likely to be used in families with any of the psychosocial risk factors examined.nnnCONCLUSIONSnOur findings indicated that the use of physical discipline was associated with higher rates of reported physically aggressive behaviors in early childhood as well as with the presence of familial psychosocial risk factors.

Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach

Objective To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. Study design Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9‐member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5‐level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. Results The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. Conclusions A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.

Dataset on Psychosocial Risk Factors in Cases of Fatal and Near-Fatal Physical Child Abuse

This article presents the psychosocial risk factors identified in the cases of 20 children less than four years of age who were victims of fatal or near-fatal physical abuse during a 12 month period in the Commonwealth of Kentucky. These data are related to the article “History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse” (Pierce et al., 2017) [1].

Are negative/unrealistic parent descriptors of infant attributes associated with physical abuse?

Parents perceptions of child behavior influence their responses to the child and may be important predictors of physical abuse. We examined whether infants 12 months of age or younger who were described with negative or developmentally unrealistic words were more likely than other infants to have been physically abused. As part of a prospective observational multicenter study investigating bruising and familial psychosocial characteristics, parents were asked to (1) describe their childs personality, and (2) list three words to describe their child. Four independent raters coded parent responses using a qualitative content analysis, identifying descriptors of infants and classifying each as positive, neutral, or negative/unrealistic. A medical expert panel, blinded to the psychosocial data, separately categorized each case as abuse or accident. We then analyzed the potential association between negative/unrealistic descriptors and abusive injury. Of 185 children enrolled, 147 cases (79%) were categorized as accident and 38 (21%) as abuse. Parents used at least one negative/unrealistic descriptor in 35/185 cases (19%), while the remaining 150 cases (81%) included only positive or neutral descriptors. Of the infants described with negative/unrealistic words, 60% were abused, compared to 11% of those described with positive or neutral words (pu202f<u202f.0001; age group-adjusted ORu202f=u202f9.95; 95% confidence interval [3.98, 24.90]). Though limited by sample-size, this pilot study informs future work to create a screening tool utilizing negative/unrealistic descriptors in combination with other predictive factors to identify infants at high risk for physical child abuse.