Only Half of Abused Children Evaluated for Occult Fracture

Jenni Laidman

July 13, 2015

Despite some 20 years of recommendations to perform a skeletal survey on infants and toddlers with injuries associated with abuse, hospital personnel failed to conduct such surveys in roughly half of suspected abuse cases, according to results from a study published online July 13 in Pediatrics.

Joanne N. Wood, MD, MSHP, from the Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues examined data from 4486 children younger than 2 years with a diagnosis of abuse or injuries often associated with abuse at 366 hospitals from 2009 to 2013.

The study indicated that 48% of children with an abuse diagnosis and 51% of infants with traumatic brain injury were evaluated with a skeletal survey for occult fracture. Only 53% of infants with femur fractures were examined for further fractures, the researchers found.

Previous studies suggest that skeletal surveys would have revealed occult fractures in approximately 25% to 30% of the children in the study, which means about 1 in every 7 or 8 children might have had an undiagnosed occult fracture, the authors report.

However, Kristine A. Campbell, MD, associate professor, Department of Pediatrics, University of Utah, Salt Lake City, the author of an accompanying commentary, notes that a lack of research demonstrating how examinations for occult fractures help the child medically or legally may contribute to this lack of skeletal surveys in suspected abuse victims.

"Unfortunately, current systems of child protection ask pediatricians to perform and disclose medical interventions without the return of outcome data needed to evaluate the effectiveness of these interventions," Dr Campbell writes.

"Although study after study suggests that this skeletal survey may describe an unhappy collection of classic metaphyseal lesions and healing rib fractures, not a single study suggests that this skeletal survey will contribute to immediate health or long-term well-being in this child. No study reveals how often occult fractures require surgical intervention, and no study reveals how often occult fractures provide the critical evidence to assure a child’s protection by caregivers, caseworkers, judges, or juries," Dr Campbell writes.

In the current study, the researchers analyzed data from the Premier Perspective Database to examine inpatient and emergency department encounters with children younger than 2 years diagnosed with physical abuse or infants younger than 1 year with non-motor-vehicle injuries frequently attributed to abuse, specifically traumatic brain injury and femur fracture.

The authors found racial and socioeconomic disparities between children who received skeletal surveys and those who did not. Black children diagnosed with physical abuse were half as likely as white children to undergo an evaluation (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.36 - 0.64), Hispanic children were nearly twice as likely as white children to undergo evaluation (OR, 1.09; 95% CI, 0.68 - 1.76), and children of other ethnicities were slightly less likely than white children to be evaluated (OR, 0.79; 95% CI, 0.61 - 1.03).

Infants with traumatic brain injury were more likely to evaluated if they had government insurance (OR, 2.38; 95% CI, 1.73 - 3.25) compared with those with private insurance.

Hospitals that cared for higher volumes of young, injured children were more likely to evaluate for occult fractures in children with a diagnosis of abuse or with injuries associated with a high likelihood of abuse, the study found. Teaching hospitals were more likely to conduct skeletal screening than nonteaching hospitals (OR, 1.59; 95% CI, 1.15 - 2.20). Hospitals in the South (OR, 1.72; 95% CI, 1.14 - 2.59) were more likely to conduct a skeletal survey than those in the Midwest for children diagnosed with physical abuse, followed by those in the West (OR, 1.30; 95% CI, 0.81 - 2.09).

Children younger than 1 years with a diagnosis of physical abuse were more likely to undergo evaluation (OR, 2.79; 95% CI, 2.30 - 3.37) than those between ages 1 and 2 years.

Both the American Academy of Pediatrics and the American College of Radiology recommend skeletal surveys in children with an abuse diagnosis or with injuries often associated with abuse. Authors of the Pediatrics study advocate for "a more standardized approach" to skeletal evaluations.

"Over the past 25 years, research has repeatedly highlighted missed opportunities to evaluate and diagnose abuse in young, injured children suffering from undiagnosed injuries as well as ongoing abuse," the authors write. "Research has also revealed that racial and [socioeconomic status–based] biases influence decision-making regarding child abuse evaluations and diagnoses." A guideline calling for universal occult fracture evaluation could eliminate racial and socioeconomic disparities and increase detection of abuse, the authors write.

"The marked variation in occult fracture evaluation rates among infants with high-risk injuries raises concerns for missed opportunities to detect abuse and protect children. These results highlight an opportunity to improve quality of care for this vulnerable population," the authors conclude.

The authors have disclosed no relevant financial relationships. Dr Campbell has disclosed that her institution receives financial compensation for expert witness testimony in suspected child abuse cases for which she has been subpoenaed to testify.

Pediatrics. Published online July 13, 2015.

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