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Distinguishing inflicted versus accidental abdominal injuries in young children
Joanne Wood1, David M Rubin, Michael L Nance
1The Center for Child Protection and Health, Division of General Pediatrics, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. woodjo@email.chop.edu
Insights
Young children with inflicted abdominal injuries often have more severe injuries and delayed care. However, delayed care is not specific to inflicted trauma, also occurring in some accidental injuries.
Area of Science:
- Pediatric Trauma Surgery
- Abdominal Injury Mechanisms
- Child Abuse Detection
Background:
- Abdominal trauma in young children can result from accidental or inflicted mechanisms.
- Differentiating between accidental and inflicted abdominal injuries is crucial for appropriate medical and legal intervention.
- Delayed presentation for medical care is a potential indicator of inflicted injury, but its specificity requires investigation.
Purpose of the Study:
- To compare the clinical presentation of abdominal trauma in young children across high-velocity accidental (HVA), low-velocity accidental (LVA), and inflicted injury groups.
- To evaluate the hypothesis that a delay in seeking medical care is a strong predictor of inflicted abdominal trauma in children.
Main Methods:
- A retrospective chart review was conducted at a Level I pediatric trauma center from 1991 to 2001.
- The study included children younger than 6 years with abdominal injuries and an Abbreviated Injury Scale (AIS) score of 2 or greater.
- Data abstracted included demographics, presentation, injury mechanism, and diagnoses, with specific definitions for accidental (HVA/LVA) and inflicted trauma.
Main Results:
- Of 121 children, 77 had HVA, 31 had LVA, and 13 had inflicted injuries.
- Inflicted injuries were associated with a higher likelihood of hollow viscus injury and combined solid and hollow viscus injuries (p < 0.001).
- Delayed presentation (>12 hours) was significantly more common in inflicted (54%) and LVA (35%) groups compared to HVA (0%), but lacked high specificity for abuse.
Conclusions:
- Young children with inflicted abdominal injuries tend to present with more severe and multiple injuries, often with a delay in care.
- While delay in seeking care is observed in inflicted trauma, it is not a specific indicator and also occurs in some low-velocity accidental injuries.
- Clinical presentation and injury patterns, in addition to delayed care, are important in identifying inflicted abdominal trauma in pediatric patients.
Objectives:
To compare the presentation of young children with abdominal trauma caused by high-velocity accidental (HVA), low-velocity accidental (LVA), and inflicted injury, and to test the hypothesis that a delay in care is highly predictive of an inflicted injury.
Methods:
We performed a retrospective chart review at an urban Level I pediatric trauma center between 1991 and 2001 of children younger than 6 years who were admitted with abdominal injuries and an Abbreviated Injury Scale (AIS) score > or = 2. Charts were abstracted for demographic information, history of presentation, mechanism of injury, and diagnoses. Accidental injuries were defined as high velocity (motor vehicle crash or a fall from > 10 feet) or low velocity (household trauma, bicycle crash, or a fall from < 10 feet). Inflicted trauma was defined as a constellation of unexplained injuries, confessions by a perpetrator, or disclosure by the victim.
Results:
Of the 121 children in the study, 77 (64%) had HVA injuries, 31 (26%) had LVA injuries, and 13 (11%) had inflicted injuries. Solid organ injuries (e.g., liver, spleen, and kidney) were most common in all groups, and abused children were significantly more likely to have suffered a hollow viscus injury (p = 0.03). Abused children were also significantly more likely to have suffered injuries with an AIS score >3 and combined hollow viscus and solid organ injuries than the HVA group or the LVA group (p < 0.001). Presentation for medical care occurred within 12 hours for 100% of the HVA group but only 65% of the LVA group, and 46% of the abuse group (p < 0.001). Presentation to care at greater than 12 hours was neither specific nor highly predictive of abuse, as some children with LVA injuries presented for care late despite developing symptoms shortly after their injury occurred (specificity, 65% [95% confidence interval, 45-81%]; positive predictive value, 39% [95% confidence interval, 17-64%]).
Conclusion:
Young children with inflicted abdominal injuries are more likely to have more severe injuries, multiple injuries, and a delay in seeking care than young children with accidental abdominal trauma. However, delay in seeking care is not specific for inflicted injury and occurs in some children with LVA abdominal trauma.
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