Child Abuse Screening Varies in Pediatric Hospitals

October 15, 2012 — Hospitals vary in the implementation of recommended screening for occult fractures in young children, according to a study published online October 15 in Pediatrics.

One third of children younger than 2 years who have been physically abused have occult fractures. Documenting and dating these events can aid child protective services and law enforcement authorities in identifying abusers. The information can also help healthcare providers identify patterns that may guide them in distinguishing accidental from intentional fractures in the future.

The American Academy of Pediatrics recommends a skeletal survey for all children younger than 2 years who are suspected of being abuse victims. Children's hospitals vary in how their child abuse services operate, and the variability has not been assessed. Prior reports have indicated that a patient's socioeconomic group and/or race may play a role in whether screening is conducted.

Joanne N. Wood, MD, MSHP, from the Division of General Pediatrics and PolicyLab, the Children's Hospital of Philadelphia, and the Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues performed a retrospective study of children younger than 2 years who were diagnosed with physical abuse and of infants younger than 1 year who have femur fracture or traumatic brain injury (TBI) not associated with motor vehicle accidents. Patients were admitted to 40 children's hospitals selected from the Pediatric Health Information System database from January 1, 1999, to December 31, 2009.

The researchers compared the type of child abuse service at each hospital with rates of compliance with guidelines. Primary outcome was procedure or billing code for skeletal survey or radionuclide bone scan.

The investigators used data from a survey by the National Association of Children's Hospitals and Related Institutions from 2008 to create a scale representing the level of child abuse detection effort: 1, no services; 2, child abuse services; 3, child abuse team; and 4, child abuse program. Data were available for 22 of the 40 surveyed institutions: 19 hospitals had level 4 services and 3 had level 3 detection efforts.

Screening was conducted for 83% of 10,170 children younger than 2 years with a diagnosis of child abuse, for 68% (95% confidence interval [CI], 68% - 69%) of 9942 infants with TBI, and for 77% (95% CI, 76% - 79%) of 2975 infants with femur fractures. The researchers adjusted for injury severity (using injury diagnosis coding software), patient characteristics (including age, sex, race, and Medicaid status), and year of admission. The investigators used logistic regression to analyze the association between child abuse services category and rate of occult fracture screening.

The hospitals varied significantly in their adherence to guidelines, from 55% (95% CI, 24% - 85%) to 93% (95% CI, 89% - 97%). The presence of a comprehensive child abuse program (n = 19) vs a child abuse team (n = 3) was associated with increased screening for occult fractures (odds ratio, 2.42; 95% CI, 1.41 - 4.16; P = .001).

Rates of screening varied almost 2-fold among infants who had TBI and more than 2-fold among infants with femur fractures after adjusting for patient characteristics. Therefore, the findings do not support past suggestions that screening is more likely in institutions that primarily serve black and low-socioeconomic-level populations, the researchers conclude.

Limitations of the study include its reliance on coding information and a lack of information on previous screenings at other locations.

Dr. Wood's institution has been paid for her testimony in child abuse cases. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 15, 2012. Abstract