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Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition
Emily A Eismann1, Robert Allan Shapiro, Kathi L Makoroff
1From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center.
Insights
Nearly half of infants under 6 months with visible injuries did not receive a physical abuse evaluation. Occult fractures and intracranial hemorrhages were common, even with minor-appearing injuries, highlighting the need for provider training.
Area of Science:
- Pediatrics
- Forensic Medicine
- Emergency Medicine
Background:
- Visible injuries in infants under 6 months can indicate physical abuse.
- Current evaluation practices for suspected child abuse in this age group are not well-defined.
- Identifying predictors for thorough evaluation is crucial for early detection.
Purpose of the Study:
- To identify predictors of physical abuse evaluation in infants under 6 months with visible injuries.
- To determine the prevalence of occult fractures and intracranial hemorrhage in evaluated infants.
- To inform clinical practice and targeted education for healthcare providers.
Main Methods:
- Retrospective study of infants aged 6 months or younger with visible injuries.
- Data collected from July 2013 to January 2017 at a pediatric hospital emergency department and urgent care.
- Analysis of sociodemographics, treatment site, provider, injury characteristics, and history as predictors.
Main Results:
- 47% of 378 infants with visible injuries did not receive a skeletal survey.
- Skeletal surveys were less common in older infants, Black patients, urgent care settings, and with non-pediatric emergency medicine-trained providers.
- Occult fractures were found in 25% and intracranial hemorrhage in 24% of evaluated infants, including those with seemingly minor injuries.
Conclusions:
- A significant proportion of infants with visible injuries are not evaluated for physical abuse.
- Provider experience and training significantly impact the likelihood of physical abuse evaluation.
- Seemingly minor injuries can conceal occult fractures and intracranial hemorrhage, necessitating consideration of physical abuse in all injured infants under 6 months.
Objectives:
To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated.
Methods:
Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage.
Results:
Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%).
Conclusions:
About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.
