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Screening for Child Abuse in Children With Isolated Skull Fractures
Stephanie Y Chen1, Leland Gao1, Karen Kay Imagawa
1From the Divisions of Pediatric Surgery.
Insights
Screening for child abuse is crucial for infants with isolated skull fractures (ISF). Social work consultation for all ISF patients can help decrease the risk of missed physical abuse.
Area of Science:
- Pediatric emergency medicine
- Child abuse and neglect
- Trauma care
Background:
- Head trauma is a leading cause of child abuse fatalities.
- Recurrent child abuse encounters increase morbidity.
- Isolated skull fractures (ISF) in children are often managed conservatively in emergency departments.
Purpose of the Study:
- To determine physical abuse screening patterns in an emergency department (ED) for children with ISF.
- To evaluate the effectiveness of social work assessments in identifying potential child abuse cases.
Main Methods:
- Retrospective review of children aged 3 years and younger with ISF from 2015-2019.
- Stratification by age (<12 months, ≥12 months) and injury circumstances (witnessed vs. unwitnessed).
- Primary outcome: social work (SW) assessment; Secondary outcomes: Child Protective Services (CPS) referral and subsequent ED encounters.
Main Results:
- 17/22 (88.2%) of younger, unwitnessed ISF patients received SW assessment, with 8/17 (47.1%) requiring CPS referral.
- 14/23 (60.9%) of younger, witnessed ISF patients received SW assessment, with no CPS referrals.
- 4/22 (18.2%) unwitnessed and 9/44 (20.5%) witnessed injury patients returned to the ED, including two infants with recurrent trauma.
Conclusions:
- Social work consultation should be considered for all pediatric patients with isolated skull fractures.
- This approach may decrease the risk of missed physical abuse in this vulnerable population.
Objective:
Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF.
Methods:
A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year.
Results:
Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma.
Conclusions:
To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.
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