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Non-Accidental Study Journal Scan

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Non-Accidental Study Journal Scan Articles reviewed by Melanie Stroud, RN, BSN, MBA Pediatric Trauma Program Manager Lucille Packard Children's Hospital - Stanford Children's Health

Consistent screening of admitted infants with head injuries reveals high rate of nonaccidental trauma Paul T. Kim, Jillian McCagg, Ashley Dundon, Zach Ziesler, Suzanne Moody, Richard A. Falcone Jr J Pediatr ic Surg. 2017 Nov; 52(11):1827 - 1830. doi: 10.1016/j.jpedsurg.2017.02.014. Epub 2017 Mar 11.

Abstract Article: Received 28 November 2016Received in revised form 23 January 2017Accepted 22 February 2017Available online xxxxKey words: Child abuse Head injury Sk eletal survey Disparity

Purpose: Implementation of a nonaccidental trauma (NAT) screening guideline f or the evaluation of infants ad mitted with an unwitnessed head injury has eliminated screening disparities. This study sought to determine the overall NAT rate and key predictive factors using this guideline. Methods: All infants screened via the guideline from 2008 to 2015 were retrospectively reviewed. The overall rate of NAT as determined by our child abuse team was determined. In addition, a logistic re gression model was developed to evaluate potential predictors of increased risk of NAT. Results: A total of 563 infants were screened with an overall rate of NAT of 25.6% (n = 144). NAT screening was consistent across race and insurance status. By univaria te analysis, patients with government insurance or no insurance had a significantly higher rate of NAT, but race was not a factor. Also NAT victims had significantly higher ISS. Skeletal survey showed high positive predictive value of 94%. When regression modeling was performed, ISS, abnormal skeletal survey and having public or no insurance were significantly correlated with NAT, while race showed no correlation.

Conclusion: One quarter of infants admitted with a head injury not witnessed in a public situ ation were identified as the victims of NAT. The high rate of abuse among this population supports routine screening in order to avoid missing intentional injuries and preventing future injuries. Race is not a predictor of NAT, but insurance status, as a p roxy for socioeconomic status, is correlated, and further investigation is needed. Level of evidence : III

Review: Good evidence. Fairly l arge population for a children's study, more investigation needed with more children.

Identification and Evaluatio n of Physical Abuse in Children. Hoehn EF, Wilson PM, Riney LC, Ngo V, Bennett B, Duma E. Pediatric Ann. 2018 Mar 1; 47(3):e97 - e101. doi: 10.3928/19382359 - 20180227 - 01.

Abstract Child physical abuse affects hundreds of thousands of children annually and i s an important cause of morbidity and mortality in children. Pediatric health care providers play a key role in the recognition and treatment of suspected child abuse. Abusive injuries are often missed, which may lead to dire consequences for the child. St andardized screening tools and treatment guidelines can enhance early recognition of child abuse. This article reviews key findings in a medical history and physical examination that should raise suspicion for abuse. We also review the recommended evaluati on that should occur when child abuse is suspected, as well as indications for reporting to child protective services. [ Pediatric Ann. 2018 ; 47 (3):e97 - e101.].

Review: Excellent article with relation to key findings to raise suspicion and use of standardizi ng screening tools and guidelines.

Major trauma from suspected child abuse: a profile of the patient pathway Ffion C Davies1, Fiona E Lecky2, Ross Fisher3, Marisol Fragoso - Iiguez4, Tim J Coats5 BMJ. Emergency Medicine Journal

Abstract Background Networked organised systems of care for patients with major trauma now exist in many countries, designed around the needs of the majority of patients (90% adults). Non - accidental injury is a significant cause of paediatric major trauma and has a different injury and age profile from accidental injury (AI). This paper compares the prehospital and in hospital phases of the patient pathway for children with suspected abuse, with those accidentally injured. Methods The paediatric database of the national traum a registry of England and Wales, Trauma Audit and Research Network, was interrogated from April 2012 (the launch of the major trauma networks) to June 2015, comparing the patient pathway for cases of suspected child abuse (SCA) with AI. Results In the stu dy population of 7825 children, 7344 (94%) were classified as AI and 481 (6%) as SCA. SCA cases were younger (median 0.4 years vs 7 years for AI), had a higher Injury Severity Score (median 16vs9 for AI), and had nearly three times higher mortality (5.7%vs 2.2% for AI). Other differences included presentation to hospital evenly throughout the day and year, arrival by non - ambulance means to hospital (74%) and delayed presentation to hospital from the time of injury (median 8 hours vs 1.8 hours for AI). Despit e more severe injuries, these infants were less likely to receive key interventions in a timely manner. Only 20% arrived to a designated paediatric - capable major trauma centre. Secondary transfer to specialist care, if needed, took a median of 21.6 hours f rom injury (vs 13.8 hours for AI).

Conclusion: These data show that children with major trauma that is inflicted rather than accidental follow a different pathway through the trauma system. The current model of major trauma care is not a good fit for the w ay in which child victims of suspected abuse present to healthcare. To achieve better care, awareness of this patient profile needs to increase, and trauma networks should adjust their conventional responses.

Review: Very interesting article using a large population of children in the U.K. Brings pause to the fact that non - accidental trauma does not always come in to the trauma center in a conventional way where a trauma alert would be called. Often more times subtle findings and delays because of mechanism of injury.

Missed Fractures in Infants Presenting to the Emergency Department With Fussiness. Kondis JS1, Muenzer J, Luhmann JD. Pediatr ic Emerg Care. 2017 Aug ; 33 (8):538 - 543. doi: 10.1097/PEC.0000000000001106.

Abstract OBJECTIVES: The aim of this s tudy was to evaluate incidence of prior fussy emergency visits in infants with subsequently diagnosed fractures suggestive of abuse.

METHODS: This was a retrospective chart review of infants younger than 6 months who presented to the pediatric emergency d epartment (ED) between January 1, 2006, and December 31, 2011. Inclusion criteria included age 0 to 6 months, discharge diagnosis including "fracture," "broken" (or break), or "trauma" or any child abuse diagnosis or chief complaint of "fussy" or "crying" as documented in the electronic medical record by the triage nurse.

RESULTS: Three thousand seven hundred thirty - two charts were reviewed, and 279 infants with fractures were identified. Eighteen (6.5%) of 279 infants had a prior ED visit for fussiness wi thout an obvious source. Of these, 2 had a witnessed event causing their fracture, and therefore the fracture was not considered concerning for abuse. The remaining 16 had fractures concerning for abuse. Mean age was 2.5 (SD, 1.2) months. Fifteen (83%) of 18 infants were 3 months or younger at the time of the fussy visit. The mean interval between the first and second ED visits was 27 days (median, 20 days). Thirty - nine percent were evaluated by a pediatric emergency medicine - trained physician during their initial fussy visit, whereas 78% were evaluated by pediatric emergency medicine - trained physician during their subsequent visit. Most common injuries were multiple types of fractures followed by extremity and rib fractures.

CONCLUSIONS: Fractures concerni ng for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse. Review: Agree with authors that we sometimes mis s injury with the vague fussiness and crying of a non - talking infant that canít tell us where they are hurting. Nice article, could be added to a larger study population.

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