Suzanne P. Starling

Updated guidelines for the medical assessment and care of children who may have been sexually abused

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.

The Presence of Bruising Associated With Fractures

OBJECTIVE To determine the occurrence of bruising near the site of fracture in a group of children with inflicted fractures. DESIGN Case series. SETTING Two childrens hospitals. PARTICIPANTS Suspected child abuse victims with fractures. MAIN OUTCOME MEASURE The presence of bruising and fracture in a single body region or appendage. RESULTS The study included 192 children with inflicted fractures. No bruising was found in 111 (57.8%) of the study participants. Forty patients (20.8%) had bruising near the site of at least 1 fracture. Of these, bruising or subgaleal hematoma near the site of a skull fracture was seen most often, in 43.3% of patients. Bruising in association with extremity fractures was seen much less commonly, ranging from 3.8% (n = 2) of children with tibia fracture to 16.7% (n = 1) of children with fibula fracture. Rib fractures also were associated uncommonly with bruising. When skull fractures are excluded, 45 (8.1%) of 555 fractures had bruising near the fracture site, in 13 (6.8%) patients. CONCLUSIONS In children with inflicted skeletal trauma, the fractured bones that most frequently have associated bruising are the skull bones. The presence of bruising near the fracture site is uncommon in extremity or rib fractures.

Core Content for Residency Training in Child Abuse and Neglect

Since the identification of child abuse as a medical diagnosis, physicians have become resources to children, families, and communities to assist in diagnosing abuse, consulting with community agencies, testifying in courts of law, administering abuse prevention programs, and participating on teams to investigate and manage child abuse. Because the distribution of pediatric specialists in child abuse is limited, primary care physicians often are asked to perform these functions. Even in the face of this increasing demand, the education of physicians in the field of child abuse is very limited. Primary care residency programs can provide a good initial base to prepare physicians for forensic evaluations. This document outlines the basic elements of residency education in child abuse and neglect.

Pelvic fractures in infants as a sign of physical abuse

OBJECTIVE The purpose of this article is to describe pelvic fractures in two abused male infants, and to determine if the literature describes pelvic fractures in infants as suspicious for child physical abuse. RESULTS Two infants are described with unexplained pelvic fractures. While in one case child abuse was obvious, careful attention to the radiological evaluation and case history led to the correct diagnosis of child abuse in the second case. A search for information regarding pelvic fractures in children resulted in information limited to the radiological and surgical literature. CONCLUSIONS Medical providers frequently encounter children with fractures suspicious for child abuse. The most common fractures seen in abused children are metaphyseal, rib, skull, and long bone fractures. This report illustrates that pelvic fractures occurring in the absence of serious, well documented accidents should be considered highly suspicious for child physical abuse.

Characteristics of falls and risk of injury in children younger than 2 years.

Introduction: Although many studies have shown that short falls by children rarely result in serious injury, no recent study in the United States has assessed the prevalence and the characteristics of such falls. Because the history of a short fall often is given in the instance of suspected child abuse, data addressing the characteristics, the frequency, and the severity of such falls would assist in abuse investigations. Methods: Anonymous questionnaires were distributed at primary care offices to parents of children younger than 5 years. Parents answered a series of questions regarding any falls their children had sustained before the age of 2 years. Information gathered included the age of the child at the time of the fall, the details about the fall, the medical attention sought, and any injuries sustained. Results: We received a total of 307 eligible surveys. There were 209 falls reported for 122 children. Only 24% of those children sustained any injury as a result of the fall. Most (85%) of the children who sustained injuries had a bruise or a bump. Of the 20% (40 children) who were brought for medical care, only 13 children received medical treatment. The most severe injuries were in 2 children who sustained concussions; only 4 children had permanent injury (cutaneous scars). Children who fell on a hard surface were 6 times more likely to have an injury compared with children who fell on a soft surface (P = 0.001) In addition, for every 1 unit increase in fall height, risk of injury increased by a factor of 2.3. Conclusions: In short falls, ground surface and fall height were significant predictors of injury risk. The results of this study also support the opinion that short falls rarely cause injury. Therefore, a history of a short fall in a seriously injured child should raise the suspicion of child abuse.

Child abuse and forensic pediatric medicine fellowship curriculum statement

Physicians have been involved in the diagnosis and treatment of victims of child abuse and neglect for more than 35 years. In the past decade, a cadre of physicians has developed extensive expertise in the field. Now, physicians are requested for expert consultation by medical, investigative, and legal colleagues. As the field advances, it has become necessary to train more physicians in the field of child abuse and forensic pediatrics as well as to standardize the curricula of the existing fellowships. A joint working group of the American Academy of Pediatrics Section on Child Abuse and Neglect and the Forensic Pediatrics Physician Leadership Group convened to develop a curriculum for medical fellowships in child abuse and neglect. The authors present the model curriculum developed by this group.

Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review

OBJECTIVES (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions. METHODS Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey. RESULTS The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008). CONCLUSIONS Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse.

Inter-rater reliability in child sexual abuse diagnosis among expert reviewers

OBJECTIVES To determine how well experts agree when assessing child sexual abuse cases. METHODS A total of twelve physician subjects were recruited and voluntarily enrolled from an existing peer review network. Experts from the network had been chosen for their experience in the field and their affiliation with childrens advocacy centers. Each expert submitted three cases of prepubertal female genital examinations clearly demonstrable of the case findings. Submitted cases included demographics, history, physical and genital exam findings, photodocumentation, and diagnosis. Experts reviewed each submitted case and labeled the case negative for physical finding(s), positive for physical finding(s), or indeterminate. Cases were analyzed to determine the level of agreement. RESULTS Thirty-six cases were submitted for use in this study; one case was excluded prior to starting the review process. After all experts completed their reviews the authors reviewed the cases and results. Two additional cases were excluded, one due to poor quality photodocumentation and one for not meeting the study criteria. Thirty-three cases were used for data analysis. All 12 expert reviewers agreed in 15 of the cases. Overall, in 22 of 33 (67%) cases at least 11 of the 12 reviewers agreed with the original diagnosis. Six of 33 (18%) cases had variable agreement (8-10 reviewers agreed with original diagnosis) among reviewers; 5 of 33 (15%) cases had poor or mixed agreement (7 or less reviewers agreed with original diagnosis). CONCLUSIONS Experts exhibit consensus in cases where the findings clearly are normal and abnormal, but demonstrate much more variability in cases where the diagnostic decisions are less obvious. Most of the diagnostic variability is due to interpretation of the findings as normal, abnormal or indeterminate, not on the perception of the examination findings themselves. More research should be done to develop a national consensus on the accurate interpretation of anogenital examination findings. Photographic image quality plays an important role in this quality review process and universally needs to be improved.

Vaginal Laceration as a Result of Blunt Vehicular Trauma

BACKGROUND Sexual abuse often is the primary diagnosis considered when prepubertal girls present with vaginal trauma. Although sexual abuse is very concerning and should remain high in the differential diagnosis, a variety of accidental injuries also can cause genital injury. CASE A 5-year-old girl presented to the emergency department with genital bleeding after a vehicle rolled over her pelvis. She had isolated vaginal lacerations on exam. SUMMARY AND CONCLUSION Extreme pelvic compression is an adequate mechanism of injury in a child presenting with vaginal laceration.

Transverse Fracture of the Distal Femoral Metadiaphysis A Plausible Accidental Mechanism

Objectives: This study describes the mechanism of injury of an impacted transverse fracture of the distal femoral metadiaphysis. Individual experience by child abuse pediatricians with this fracture type has suggested that it is less associated with inflicted trauma than was described in a prior case series. Methods: Case contributions were solicited from an international group of child abuse clinicians. Eighteen cases were accepted for analysis. Cases were categorized as abuse or nonabuse by a predefined categorization scheme. Differences in the 2 groups were analyzed by Fischer exact test. Results: Thirteen cases (72%) were determined to be nonabusive, and 5 (28%) were determined to be from abuse. Additional skeletal injuries on skeletal radiograph survey, absence of any explanatory history, and significant changes in repeated histories identified cases of abuse. A short fall was accepted as the explanation for the nonabuse cases, with some indication that direct impact on the knee explained the injury. Conclusions: Impacted transverse fracture of the distal femoral metadiaphysis may occur as a result of an accidental short fall of young children. A traditional abuse evaluation should be pursued in these cases, but with an absence of additional skeletal findings, and a history of a fall, it is likely that an accidental mechanism accounts for the injury.