Clinical and Radiographic Characteristics Associated With Abusive and Nonabusive Head Trauma: A Systematic Review

461

301

Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.

Section: Head Injuriesmentioning

confidence: 99%

The Evaluation of Suspected Child Physical Abuse

Christian¹

2015

461

301

“…SS was rated necessary in all clinical scenarios involving SDHs but not in all scenarios involving EDHs, which have been associated with a lower risk of abuse. 21,22 In addition, SS was not deemed necessary when a tiny extra-axial hemorrhage directly under a skull fracture was found in children 12 to 23 months old with a history of trauma and infants 6 to 11 months old with a history of a high fall (≥3 feet). Panelists had specifically requested the addition of scenarios specifying a tiny extraaxial hemorrhage under a skull fracture, as this injury was thought to be consistent with a direct impact mechanism, such as a fall, and of less concern for abuse than larger SDHs.…”

Section: Discussionmentioning

confidence: 99%

“…SS was deemed universally necessary in children <6 months old, likely because they are much less likely than older infants and toddlers to suffer from accidental ICH due to their lack of independent mobility. 21 Nonetheless, universal evaluation in these populations is not the norm, which may contribute to missed opportunities to diagnose AHT. 7,11 Studies have shown that age-and injury-specific clinical guidelines regarding SS use have the potential to eliminate disparities in evaluation and improve abuse detection.…”

Section: Discussionmentioning

confidence: 99%

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

Paine

Scribano²,

Localio

et al. 2016

BACKGROUND AND OBJECTIVE: As evidenced by the variation and disparities in evaluation, there is uncertainty in determining which young children with intracranial hemorrhage (ICH) should undergo evaluation with skeletal survey (SS) for additional injuries concerning for abuse. We aimed to develop guidelines for performing initial SS in children <24 months old presenting with ICH by combining available evidence from the literature with expert opinion.

“…Although some children with isolated skull fractures may require hospital admission for on-going symptoms or evaluation of nonaccidental trauma, [15][16][17][18] outpatient care with close follow-up is a safe option for many. 10 At our study institution, the baseline hospitalization rate for children with isolated skull fractures was similar to the national average.…”

Section: Methodsmentioning

confidence: 99%

A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures

Lyons¹,

Stack²,

Monuteaux³

et al. 2016

BACKGROUND AND OBJECTIVE: Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures. METHODS: We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database. RESULTS: We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5–16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%–77%) and decreased to 46% (34/72, 95% confidence interval, 35%–60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%. CONCLUSIONS: We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.