U.S. hospitals miss followup for suspected child abuse

NIH-funded study finds less than half of suspicious fractures get a closer look

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Barrett Whitener: Many U.S. hospitals may be missing the chance to find out if babies and toddlers have been physically abused. Researchers funded by the National Institutes of Health found a large difference in whether hospitals followed long-standing guidelines from the American Academy of Pediatrics to order additional x-rays for children suspected of being victims of abuse.

For children under age two, a broken thigh bone or a head injury not received in a car crash may signal a pattern of earlier abuse. Follow up x-rays may reveal earlier, unreported bone breaks that have begun to heal and so can help confirm the suspicion of abuse.

The study examined records from over 300 hospitals and almost 5,000 children, and found that only about half of small children with these injuries were screened for hidden fractures—many times, even when a child was known to have been abused previously.

How frequently screening took place varied greatly from one hospital to another. Some hospitals screened every infant with a thigh bone fracture; a few others screened none at all.

From the National Institutes of Health, I'm Barrett Whitener. This is "Research Developments," a podcast from the NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development, the NICHD.

Joining me today is Joanne Wood, the study's lead researcher. She's a faculty member at PolicyLab at the Children's Hospital of Philadelphia, and Assistant Professor of Pediatrics at the University of Pennsylvania's Perelman School of Medicine. Thanks for joining me today, Dr. Wood.

Joanne Wood: Thank you for having me.

Mr. Whitener: First, how frequent is injury from child abuse in the United States? Do we know how many children are abused each year?

Dr. Wood: What we know is largely dependent on Child Protective Services data. Each year in the United States, over 120,000 children are determined by Child Protective Services to be victims of physical abuse. Unfortunately, that data also underestimates the number of children who are physically abused each year.

Many children who are victims of abuse, even those who are injured severely, may not be reported to Child Protective Services. We don't know exactly how many of those children suffer serious injuries that require medical care. We do know that several thousand children receive medical care in emergency departments and inpatient settings each year due to injuries from abuse.

We also know that the highest risk group, the children that we are most likely to see severe injuries from physical abuse in, are those youngest kids, the kids that we focused on in our study. Nearly three-quarters of children who suffer from fatal child maltreatment are under the age of three years.

Mr. Whitener: Those are really heartbreaking statistics. Along with the traumatic brain injury and thigh fracture that your study focused on, what other kinds of injuries should doctors be on the lookout for, to detect potential abuse?

Dr. Wood: We looked at thigh injuries or the femur fractures and traumatic brain injuries because they're two of the more severe injuries that children may be seen in the emergency department for. But children who are victims of abuse can present with a wide range of injuries. Bruising is actually the most common injury that occurs in physical abuse. And while bruising may be a more minor injury and often doesn't require specific medical treatment, it's very important for clinicians to recognize abusive bruising.

One of those reasons is that young children who have bruises may also have hidden or "occult" injuries that the physician may not be able to detect on just physical exam. So it's important, if you see a young child with abusive bruising, to do an evaluation for occult injuries including occult fractures. The other thing is that a minor injury such as bruising can be a precursor to more severe injuries. Often when we see young children who have severe injuries such as brain injury, when we look back, we see that they've been seen in emergency departments or in the primary care provider's office with less-severe injuries, and there were opportunities to recognize that as an abusive injury and intervene and protect the child.

Now, this is a difficult thing to do, to recognize which injuries may be abusive. When you think about all the children who seek medical care in emergency departments and hospitals each year, the vast majority of them aren't victims of abuse. Children run, they play, they fall, they sustain accidental injuries all the time. So it can actually be challenging for physicians and other medical providers to identify which children may be victims of abuse.

And you need to look not just at a specific injury, but other factors. One of the more important ones is age. So we looked at femur fractures in young infants because that's a group where that type of injury is very concerning for abuse, where if you saw the same injury in an older child, the risk of abuse is much lower.

Mr. Whitener: Other studies have looked at hospital screening for child abuse. What does your study add to what we've already learned?

Dr. Wood: Our study looked specifically at the use of the skeletal survey in the evaluation of suspected or diagnosed abuse. And the skeletal survey is basically a series of over 20 x-rays that's looking for occult fractures, or breaks in the bone that a physician might not recognize just on physical exam. And young children, especially young infants, can have fractures and serious injuries that you can't detect solely on physical exam.

When we studied young children who are diagnosed with abuse, about one in four of them will have occult fractures. So, this is really an important part of the evaluation of physical abuse, and the American Academy of Pediatrics recommends that whenever physical abuse is suspected in a child under the age of two, that a skeletal survey be performed.

And so what we did was look at what percentages of young children with a diagnosis of abuse, or injuries that are associated with a high rate of abuse, were undergoing the recommended skeletal survey. And we expected to see some variations across hospitals, but as you mentioned, we saw huge variation, with some hospitals screening all kids and some screening none.

One of the things that we did notice was that hospitals that have more experience treating young kids, hospitals that have higher volumes of traumatic injuries in young kids, were overall more likely to do skeletal surveys. So this suggests that there might need to be more support and education toward hospitals that have less experience taking care of this population.

Mr. Whitener: You just touched on this, but could you speculate a bit about what might account for the huge variance or difference in hospital screening rates that you discovered?

Dr. Wood: So, I think part of it—and our study identified some hospital characteristics that were associated with different rates of screenings. So, we found that teaching hospitals were more likely to perform skeletal surveys, and that hospitals seeing more children were more likely to perform skeletal surveys. We weren't able to necessarily get at all the reasons, but potentially there may be differences in resources among hospitals.

So some hospitals may not have the technical capabilities to even be performing skeletal surveys at all times. There's also differences in the expertise and supports available. So many of the larger pediatric centers have child abuse pediatric specialists who are on call and can help advise about the appropriate evaluation for suspected physical abuse. But that's a resource that many hospitals, especially hospitals that don't specialize in pediatrics, don't have access to.

In order to sort of address some of the variations and concerns regarding missed cases of abuse, some hospitals have begun implementing specific guidelines. So there are specific guidelines—and this is something that our hospital has done—where there are clinical pathways that provide recommendations to physicians on specific injuries, and age groups, and other characteristics of an injury that should make them worry about abuse and consider an abuse workup. So there may be differences across the hospitals that we looked at, in whether or not they have clinical resources such as pathways developed.

Mr. Whitener: Is there anything else that hospitals could do to improve their screening rates, or to help doctors be more on the lookout for these kinds of possible occult fractures?

Dr. Wood: I think one of the most important things is the standardization of care. And I think clinical pathways and guidelines, also using clinical decision support, prompts that are embedded within the electronic medical record, can be very helpful. In addition to the variation that we documented in our study, there are numerous prior studies that have shown not just variation in skeletal survey ordering and abuse evaluations, but also disparities based on demographics of the child, and I think that taking steps to educate providers about the appropriate indications for doing a skeletal survey as well as providing support resources in terms of clinical guidelines and decision support are really going to be key in addressing the variations and the disparities that we currently observe in practice.

Mr. Whitener: What are some of those disparities that you referenced?

Dr. Wood: So, this wasn't the focus of our study, but in prior work we and others have found that the socioeconomic status [SES] of a family as well as the race of the child and family are associated with differences in the likelihood of a child being evaluated for abuse—such that families of children from lower socioeconomic status or minority race are more likely to get evaluated for child abuse, while those of white or higher SES are often less likely, and this creates multiple problems. There are concerns for potential over-evaluation in some populations, which exposes children to unnecessary tests, as well as under-evaluation in populations, which then can contribute to misdiagnoses of abuse, which can put children at risk of ongoing injury and abuse.

Mr. Whitener: I also noticed in the study that evaluations for the hidden or occult fractures were also more likely to occur in the southern part of the United States.

Dr. Wood: Yes. You know, we had I think a priori hypothesized that we were expecting to see some variation, potentially based on teaching status and the experience, and we did also see some differences based on the geographic region, which were interesting. I'm not entirely sure whether—what the differences are in those hospitals that explain the difference that we saw.

Mr. Whitener: For those hospitals or doctors who are looking for more resources, to know what to check for and how to do that, can you recommend anything that they might consult?

Dr. Wood: Sure.  I think, you know, one of the great resources, the American Academy of Pediatrics Committee on Child Abuse and Neglect, provides clinical reports External Web Site Policy that have guidance for clinicians. And this year, they just updated and published in Pediatrics their core report: "The Evaluation of Suspected Child Physical Abuse," External Web Site Policy which provides guidance on some of the factors to consider in estimating whether or not a child might be at risk of abuse, as well as how to proceed and what to do if you suspect physical abuse in a young child.

There's also available online a great set of systematic reviews from the Cardiff Child Protection Systematic Reviews External Web Site Policy, or Core Info project, that has done systematic reviews on the likelihood of abuse and neglect in children with different types of injuries. 

Mr. Whitener: Where do you take the research next? Where would you like to see it go next?

Dr. Wood: It's a great question. With support from NICHD, we—our team has been in the process of working to develop more specific guidelines for clinicians on what specific injuries should prompt an evaluation for possible abuse with a skeletal survey.

So, drawing upon both the available evidence and the literature, as well as expert opinion, we developed and published guidelines that help to provide more concrete recommendations for clinicians on when to suspect abuse in a variety of injuries, including fractures, as well as bruising, and we're working on guidelines for young kids with traumatic brain injury.  Being able to provide clinicians with more concrete recommendations on specific children and specific injuries that they need to consider abuse in, will help to decrease the variation we see, help to address disparities, as well as improve our ability to detect abuse and make sure that children are being protected.

I think after that, the next step will be to prospectively implementing guidelines with clinical decision support across a variety of hospitals, not just academic centers and pediatric tertiary care centers, but community-based hospitals as well, since that's where the majority of children seek care—so that we can measure the impact of these interventions on outcomes for children.

Mr. Whitener: Thank you very much for your work on this incredibly important problem, and for talking with me today about the study.

Dr. Wood: Thank you very much for inviting me.

Mr. Whitener: I've been speaking with Dr. Joanne Wood. She's the lead author of the study, "Evaluation for Occult Fractures in Injured Children," published in the journal Pediatrics.


About the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation. For more information, visit the Institute's website at http://www.nichd.nih.gov/.

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