Oral injuries and occult harm in children evaluated for abuse

Dorfman, Molly V.; Metz, James B; Feldman, Kenneth W.; Farris, Reid; Lindberg, Daniel M.

doi:10.1136/archdischild-2017-313400

Cited by 27 publications

(31 citation statements)

References 29 publications

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“…7 Oral injuries in infants, such as frenulum tears, may also accompany or precede AHT and should prompt consideration of abuse. 8 Thus, it is crucial for the pediatric practitioner to maintain high vigilance for subtle findings that can indicate AHT and perform a careful evaluation as dictated by the clinical presentation.…”

Section: Presentation and Evaluationmentioning

confidence: 99%

Abusive Head Trauma in Infants and Children

et al. 2020

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Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject. HISTORY The evolution of the abusive head trauma (AHT) diagnosis has a long and storied history. 1-3 Earlier nomenclature included whiplash shaken infant syndrome, shaken impact syndrome, inflicted childhood neurotrauma, and shaken baby syndrome. The current term, AHT, was adopted by the American Academy of Pediatrics (AAP) in 2009 in recognition of the fact that inflicted head injury of children can involve a variety of biomechanical forces, including shaking. That change in terminology (from shaken baby syndrome), however, was misinterpreted by some in the legal and medical communities as an indication of some doubt in or invalidation of the diagnosis and the mechanism of shaking as a cause of injury. The AAP continues to affirm the dangers and harms of shaking infants, continues to embrace the "shaken baby syndrome" diagnosis as a valid subset of the AHT diagnosis, and encourages pediatric practitioners to educate

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Section: Presentation and Evaluationmentioning

confidence: 99%

Abusive Head Trauma in Infants and Children

et al. 2020

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“…Early identification of abuse is challenging, and physicians often miss the evidence of abuse that can lead to an appropriate intervention [1]. Successfully identifying abuse from particular injury patterns has been widely reported [11][12][13], yet despite this, abuse has been initially missed in 20%-30% of cases [12,14]. Consistent evidence has also shown that victims of child abuse have documented contact with the health care system, especially in the emergency department setting.…”

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confidence: 99%

Identifying Populations at Risk for Child Abuse: A Nationwide Analysis

Quiroz

Parreco

Easwaran

et al. 2020

Journal of Pediatric Surgery

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a b s t r a c tPurpose: Child abuse is a national, often hidden, epidemic. The study objective was to determine at-risk populations that have been previously hospitalized prior to their admission for child abuse. Methods: The Nationwide Readmissions Database (NRD) was queried for all children hospitalized for abuse. Outcomes were previous admissions and diagnoses. χ 2 analysis was used; significance equals p b 0.05. Results: 31,153 children were hospitalized for abuse (half owing to physical abuse) during the study period. 11% (n = 3487) of these children had previous admissions (one in three to a different hospital), while 3% (n = 1069) had multiple hospitalizations. 60% of prior admissions had chronic conditions, and 12% had traumatic injuries. Children with chronic conditions were more likely to have sexual abuse (89% vs. 57%, p b 0. 001) and emotional abuse (75% vs. 60%, p b 0. 01). 25% of chronic diagnoses were psychiatric, who were also more likely to have sexual and emotional abuse (47% vs. 5.5% and 10% vs. 1%, all p b 0. 001). Conclusion: This study uncovers a hidden population of children with past admissions for chronic conditions, especially psychiatric diagnoses that are significantly associated with certain types of abuse. Improved measures to accurately identify at-risk children must be developed to prevent future childhood abuse and trauma. Level of evidence: Level III. Type of study: Retrospective comparative study.

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“…One such intervention leveraged the previously described facilitators and addressed the challenges of recognizing injuries concerning for abuse by implementing a clinical pathway. This clinical pathway directed CED providers to call the regional CPT at YNHCH for a phone consultation if any of the following 10 injuries associated with abuse 24–31 were noted in infants during the ED visit: 1) long‐bone fracture; 2) skull fracture; 3) rib fracture; 4) intracranial injury; 5) burn; 6) solid‐organ injury (laboratory or imaging evidence); 7) bruising of the ear, neck, torso, angle of jaw, cheek, or eyelid or patterned bruising; 8) subconjunctival hemorrhage; 9) frenulum tear; or 10) if the patient was < 5 months of age and had any oral injury or any bruise (Data Supplement S1, Figure S1, available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1111/acem.14132/full). In contrast to previously published pathways that prescribed a specific diagnostic evaluation, we recommended a case‐specific diagnostic evaluation dependent on advice from the CPT (i.e., a second opinion).…”

Section: Problem Descriptionmentioning

confidence: 99%

Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments

Tiyyagura

Emerson

Gaither

et al. 2020

Academic Emergency Medicine

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Objectives Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children < 12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12 months. Methods We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan‐do‐study‐act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children < 1 year old with high‐risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). Results Evidence of special cause was identified beginning in June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8‐month period, the CPT was consulted for a mean of 47.5% of children with high‐risk injuries; this was sustained for an additional 7 months. The average percentage of infants with high‐risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. Conclusion Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high‐risk injuries. Such interventions may improve recognition of physical abuse.

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Oral injuries and occult harm in children evaluated for abuse

Abstract: Children with oral injury are at high risk for additional occult abusive injuries. Infants and mobile preschoolers are at risk. Young children with unexplained oral injury should be evaluated for abuse.

Cited by 27 publications

References 29 publications

Abusive Head Trauma in Infants and Children

Abusive Head Trauma in Infants and Children

Identifying Populations at Risk for Child Abuse: A Nationwide Analysis

Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments

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