Journal Club March 2018 - Risk Stratification and Work Up of Non-accidental Trauma

 
 Rib fractures in an infant secondary to child abuse  https://commons.wikimedia.org/wiki/File:Fractured_ribs.jpg   

Rib fractures in an infant secondary to child abuse

https://commons.wikimedia.org/wiki/File:Fractured_ribs.jpg

 

The evaluation of a child for non-accidental trauma (NAT) is an infrequent, yet high risk endeavor for emergency physicians.  Abusive head injury is the most common cause of death in cases of non-accidental trauma and up to 30% of cases of child maltreatment are misdiagnosed at first health care contact.  There is a growing body of literature that helps to frame the workup and risk stratification of children at risk for NAT.  This month’s journal club focused on three articles centered on risk factors and diagnosis of abusive injuries. 

 

 

Articles reviewed

1.  Lindberg et al.  Yield of Skeletal Survey by Age in Children Referred to Abuse Specialists, The Journal of Pediatrics; Volume 164; Number 6; June 2014.  [Pdf]

 2.  Lindberg et al.  Prevalence of Abusive Injuries in Siblings and Household Contacts of Physically Abused Children, Pediatrics; Volume 130; Number 2; August 2012. [Pubmed]

3.  Harper et al.  Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises,                   J Pediatr. 2014 Aug;165(2). [Pubmed]

 

additional reading

1.  Berkowitz – Physical Abuse of Children, The New England Journal of Medicine; 376; 17; April 27, 2017. [Pubmed]

2.  Lindberg et al – Utility of Hepatic Transaminases in Children With Concern for Abuse, Pediatrics; Volume 131; Number 2; February 2013.[Pdf]

 

LINDBERG ET AL., 2014

This retrospective secondary analysis of data prospectively gathered by the Examining Siblings To Recognize Child Abuse (ExSTRA) research network attempted to determine the yield of skeletal surveys in children < 5 years of age referred to Child Protective Services for evaluation of NAT.   The results indicate that 23% of patients who underwent skeletal survey in this study had a previously unknown fracture identified.  The rates of identification was similar in the 0-24 month age group when compared with the 24-36 month age group.  Around 50% of the injuries were “clinically silent” reinforcing the utility of imaging.

 

 Bottom Line: The American Academy of Pediatrics recommends skeletal survey in children < 2 years being evaluated for non-accidental trauma and this study supports that recommendation.  The results of this study also suggest that liberal use of skeletal surveys in children 24-36 months of age being evaluated for injuries caused by abuse may be reasonable.

 

 

LINDBERG ET AL.,  2012

This prospective, observational multicenter study of patients from 20 large academic hospitals with Child Protective services was designed to assess whether there is a higher level of abusive injuries in contacts of abused children (siblings and other children who share a home).  They used a set screening protocol based on age to identify injuries:

TWINS.jpg

12 % OF SIBLINGS HAD AN ABUSE INJURY NOTED ON IMAGING

  • Age <5 years: physical examination
  • Age <2 years: physical examination and skeletal          survey
  • Age <6 months: physical examination, skeletal survey, neuroimaging (CT or MRI)

https://www.flickr.com/photos/donnieray/14581168505

Important findings of this study were that almost 12% of siblings had an abuse injury noted on imaging and that the risk was highest with twins.  The odds ratio of fracture in a twin contact was 20.1 relative to non-twin siblings.  The other notable finding was that most of these injuries were not readily apparent on physical examination alone.

 

Bottom Line:  Siblings of abused children, particularly twins, are at exceedingly high risk for abusive injuries and should be screened for such.  Many of these injuries are “occult” utilizing physical examination alone, lending support to a liberal imaging strategy such as that employed in this study.

 

HARPER ET AL. 

This prospective secondary analysis of data prospectively gathered by the Examining Siblings To Recognize Child Abuse (ExSTRA) research network attempted to determine the rate of diagnostic testing for occult injury in infants presenting with apparently isolated bruising.  They also sought to determine the prevalence of injuries in this population.  This cohort included patients < 6 months of age with isolated bruising.  The study found that the presence of bruising increased the likelihood of diagnostic testing when compared to the cohort of patients without bruising.

 
 Percentages of injuries identified are calculated using the number of subjects as the denominator with the assumption that studies that were not ordered would be negative. New injuries represent injuries not identified on previous studies or physical examination. SS= Skeletal survey

Percentages of injuries identified are calculated using the number of subjects as the denominator with the assumption that studies that were not ordered would be negative.
New injuries represent injuries not identified on previous studies or physical examination. SS= Skeletal survey

 

In this cohort of infants < 6 months of age with an apparently isolated bruise, the yield of further diagnostic studies was significant.  A full 50% of these patients had additional injuries identified by diagnostic testing.  Skeletal survey was “positive” for new fractures in 23.3% of cases.  Neuroimaging identified a new injury in 27.4% of cases while a new abdominal injury was identified by abnormal liver function tests in 2.7% of patients.

 

Bottom Line: “You shouldn’t bruise until you can cruise” is the axiom I learned in training and the results of this study definitely bear this out.  Apparently isolated bruising in young (< 6 months of age) children should be considered abuse until proven otherwise and an aggressive diagnostic evaluation (skeletal survey and neuroimaging at a minimum) should be performed.

 
summary.png

There is a growing body of literature that helps to frame the workup and risk stratification of children at risk for NAT.  Conclusions from this month's articles include:

  • Skeletal surveys should be ordered for children < 36 months being evaluated for NAT.
  • Siblings of abused children, particularly twins, are at exceedingly high risk for abusive injuries and should be screened.
  • Isolated bruising in young (< 6 months of age) children should be considered abuse until proven otherwise.  An aggressive diagnostic evaluation (a minimum of a skeletal survey and neuroimaging) should be performed.

 

download article summaries

 
  Lindberg et al, 2014

Lindberg et al, 2014

  Lindberg ET AL, 2012

Lindberg ET AL, 2012

  Harper ET AL.

Harper ET AL.

 

Written by Nathan Mick, MD, FACEP

Edited and Posted by Jeffrey A. Holmes, MD