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Missed Recognition of Potential Abuse in Young Children Presenting to the Emergency Department: A Retrospective Study
Linda Ren1,2, Caroline Baughn1,3, Andrea Ali-Panzarella1
1Nemours Children's Health Department of Pediatrics, University of Central Florida College of Medicine, Orlando, Florida, USA.
Insights
One in three young children presenting to the emergency department (ED) with trauma had abuse-related red flags. However, comprehensive evaluations remained infrequent, highlighting a need for standardized approaches to child abuse detection.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse and Neglect Research
- Public Health
Background:
- Child abuse is a significant public health concern, often presenting with trauma-related injuries in young children.
- Early identification of abuse-related red flags in emergency departments (EDs) is crucial for timely intervention.
- Limited data exist on the prevalence of these red flags and subsequent evaluations in pediatric ED settings.
Purpose of the Study:
- To determine the prevalence of abuse-related red flags in children under 3 years old with trauma-related complaints in a pediatric ED.
- To assess the frequency of subsequent evaluations, including skeletal surveys and laboratory testing.
- To quantify the association between documented red flags and the likelihood of further evaluation.
Main Methods:
- Retrospective cohort study of 962 children under 3 years old presenting to a tertiary pediatric ED in 2019.
- Red flags were categorized (historical, physical, diagnostic, caretaker/household) and coded from electronic health records (EHRs).
- Logistic regression analyzed the association between red flags and evaluations (skeletal surveys, labs, social work consultations), adjusting for age.
Main Results:
- 33% of children (317/962) had at least one documented red flag.
- Further evaluations were infrequent: skeletal surveys (8.6%), laboratory testing (4.3%), social work consultations (1.5%).
- Children with any red flag were significantly more likely to undergo further evaluation (aOR 3.7). Specific red flag types were associated with particular evaluations.
Conclusions:
- A substantial proportion of young children with trauma in the ED exhibit red flags for abuse.
- Current rates of comprehensive evaluation following red flag identification are low.
- Standardized, nuanced approaches are needed to optimize the identification and evaluation of suspected child abuse.
Aim:
To determine the prevalence of abuse-related red flags and the frequency of subsequent evaluations among young children presenting to the emergency department (ED) with trauma-related complaints, and to quantify the association between red flags and further evaluation.
Methods:
We conducted a retrospective cohort study of children < 3 years presenting to a tertiary paediatric ED in 2019 with trauma-related chief complaints identified from structured electronic health record (EHR) data. Red flags were categorised as historical, physical, diagnostic, or caretaker/household. Two trained abstractors independently coded red flags from explicit provider documentation; discrepancies were resolved by consensus (inter-rater reliability on a 20% sample; kappa = 0.82). Outcomes were the performance of skeletal surveys, laboratory testing, and social work/child protection consultations. Logistic regression estimated the association between red flags and any subsequent evaluation, adjusting for age.
Results:
Among 962 eligible trauma-related visits, 317 children (33%) had ≥ 1 documented red flag. Across the cohort, 8.6% received a skeletal survey, 4.3% had laboratory testing, and 1.5% had a social work consultation. Children with any red flag were more likely to undergo further evaluation (adjusted OR [aOR] 3.7; 95% CI: 2.5-5.4). Historical red flags were associated with skeletal survey (OR 3.7, 95% CI: 1.3-11) and laboratory tests (OR 4.1, 95% CI: 1.3-13.6). Physical red flags were associated with skeletal survey (OR 6.4, 95% CI: 2.1-19.6) and laboratories (OR 5.3, 95% CI: 1.5-19). Diagnostic red flags were associated with skeletal survey (OR 7.0, 95% CI: 2.3-21.6) and neuroimaging (OR 2.4, 95% CI: 1.3-4.5).
Conclusion(S):
One in three children under age 3 with trauma-related ED visits had documented red flags suggestive of possible abuse, yet comprehensive evaluations were infrequent. Findings support the need for nuanced, standardised approaches that prioritise high-yield flags while avoiding extensive evaluations.
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