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Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?
Ian C Mitchell1, Bradley J Norat2, Marc Auerbach3
1From theDepartments of Surgery, University of Texas Health Science Center at San Antonio and Baylor College of Medicine, San Antonio, TX, USA.
Insights
Routine child abuse evaluations are recommended for young children with specific fractures. Children under 3 with rib fractures and those under 18 months with humeral or femoral fractures require evaluation to identify potential abuse.
Area of Science:
- Pediatrics
- Forensic Medicine
- Child Health
Background:
- Child abuse is a leading cause of death and illness in young children.
- Fractures are common indicators of abuse but may not be immediately recognized.
- Early identification of abusive injuries is crucial for child protection.
Purpose of the Study:
- To determine age-based criteria for routine child abuse evaluations in pediatric patients with fractures.
- To establish evidence-based recommendations for identifying abusive injuries in preverbal children.
Main Methods:
- A systematic review of literature from 1980-2020 was conducted.
- An evidence-based framework was developed by a consensus panel.
- Fifteen articles were included in the final analysis.
Main Results:
- 77% of children under 3 with rib fractures showed signs of abuse (96% excluding MVA).
- Abuse was identified in 48% of children under 18 months with humeral fractures.
- 34% and 25% of children under 12 and 18 months with femoral fractures were diagnosed with abuse.
Conclusions:
- Routine child abuse evaluations are recommended for children under 3 with rib fractures.
- Children under 18 months with humeral or femoral fractures should undergo routine abuse evaluations.
- These evaluations should include specialty child abuse consultation.
Objectives:
Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age.
Methods:
A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.
Results:
Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.
Conclusion:
Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).
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