A standardized protocol for screening children with suspected sentinel injuries – those suggesting risk for child abuse – could increase the accurate identification of abused children and reduce missed cases, new research suggests.
“It has been well-described that abused children frequently present with subtle signs and symptoms, and that the history may be incomplete or misleading,” Dr. Daniel M. Lindberg, of the University of Colorado, Denver, and his associates wrote. “Our data reveal an overall high rate of diagnosed abuse, but tremendous variability in evaluation and diagnosis of abuse across hospitals and injury categories. Together, these facts suggest that increased, routine, or protocolized testing for children with these injuries can identify other children with abuse that might otherwise be missed.”
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In a retrospective secondary analysis of the Pediatric Health Information System database, the researchers examined records for more than 4 million patient visits for children under 24 months old who were seen at 18 institutions between Jan. 1, 2004 and Dec. 31, 2011. Overall, 0.17% (7,062 visits) were associated with a diagnosis of abuse. But the rates of abuse diagnosis ranged widely between hospitals, from 0.04% to 0.46% (Pediatrics. 2015 Oct. 5, doi: 10.1542/peds.2015-1487.).
The researchers identified 34,564 sentinel injuries among 30,766 visits (0.7%). Nearly 90% of patients had only one sentinel injury, nearly 8% had two sentinel injuries, and nearly 3% had 3-6 sentinel injuries identified. In the 4,100,411 visits in which a sentinel injury was not identified, abuse was diagnosed in 0.03% of visits.
The researchers excluded children with a previous child abuse diagnosis or who were involved in a motor vehicle accident.
Sentinel injuries – designed to flag injuries that are unusual for the child’s age – included rib fracture, abdominal trauma, genital injury, or subconjunctival hemorrhage for children under 24 months; femur/humerus fracture, radius/ulna/tibia/fibula fracture, isolated skull fracture or intracranial hemorrhage for children under 12 months; and bruising, burns, or oropharyngeal injury for children under 6 months.
Among children with sentinel injuries, abuse diagnosis ranged from a low of 3.5% among infants with burns to 56.1% of children with rib fractures.
For children under 6 months, the rates of abuse diagnosis were 8.3% for bruises and 17% for oropharyngeal injuries. In children under 12 months, the abuse diagnosis rates were 4.3% for isolated skull fracture, 26.3% for intracranial hemorrhage, and between 18%-19% for arm or leg fracture. In children under 24 months, the abuse diagnosis rates were 8.6% in cases of subconjunctival hemorrhage, 12.3% for genital injury, and 24.5% for abdominal trauma.
Across all hospitals, 46% of children with suspected sentinel injuries received a skeletal survey, 68.6% received neuroimaging with CT or MRI, and 24.9% had hepatic transaminases tested. The American Academy of Pediatrics considers the radiographic skeletal survey to be “mandatory” for children with concern for abuse, the authors noted.
Dr. Lindberg reported providing paid expert testimony in cases of alleged child maltreatment. Two of the coauthors reported that their institutions received payment for expert witnes testimony they provided in suspected child abuse cases.