Child abuse fatalities: are we missing opportunities for intervention?

Child abuse is a leading cause of childhood morbidity and mortality and often goes unrecognized until severe injury or death has occurred. This study describes a cohort of fatally abused children and explores contacts with the health care community, which may represent missed opportunities for recognition and intervention.

Homicide deaths in children younger than 10 years were identified through medical examiners' records from a 4-county area from 1999 to 2002. Medical records from the 3 area children's hospitals were searched for health care visits by the subjects before death. Subject demographics, cause of death, injury patterns, person supervising the child, and recent contacts with the health care community were collected from medical examiner and hospital records.

Forty-four cases were identified, with 37 subjects (84%) younger than 4 years. Further analysis focused on these 37 younger subjects. Causes of death were blunt head injury, 57%; blunt torso injury, 13%; gunshot wound, 11%; fire, 8%; drowning, 8%; and poisoning, 3%. Fractures were noted in 9 children (24%), 7 children with fractures at different stages of healing. Eleven children (30%) had documented health care visits for reasons other than routine well-child care in the year before their death, including 7 children (19%) with such visits within a month before their death.

Child homicides in this cohort occurred primarily in younger children, among whom the most common cause of death was blunt trauma. Almost 20% of this subgroup had documented contact with the health care community for reasons other than routine care within a month before their death. Some of these presentations are suspicious for undiagnosed abusive injuries, which, if properly identified, could serve as opportunities for life-saving intervention.