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Child physical abuse is associated with high risk of undertriage, emergent pediatric trauma center resource utilization, and potential missed opportunities for early identification
Nia Crosby1, Jorge Alvarado Barrantes
6, Shelley Warner
6, Caitlin J. Crosier
6, Monique Motta
7, Oliver Lao
7, Dalier Rodriguez Mederos
8, Michele Markley
2, Victoria Tardiff
3, John M. Draus
3, Raphael Parrado
4, Jana Raphael
5, Patricio Lau
5, Joseph Whitmore
9, Courtney Allen
10, Christopher Snyder
61Pediatrics, Johns Hopkins All Childrens Hospital, St Petersburg, Florida, United States, 2Pediatric Surgery, Broward Health, Coral Springs, Florida, United States, 3Pediatric Surgery, Nemour Children's Health, Jacksonville, Florida, United States, 4Trauma and Critical Care Surgery, University of Florida Health, Jacksonville, Florida, United States, 5Pediatric Surgery, Nicklaus Children's Hospital, Miami, Florida, United States, 6Pediatric Surgery, Johns Hopkins All Children's Hospital, St Petersburg, Florida, United States, 7Joe Dimaggio Children's Hospital, Hollywood, Florida, United States, 8Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida, United States, 9Pediatrics, Baycare Health System, Tampa, Florida, United States, 10Pediatric Emergency Medicine, Baycare Health System, Tampa, Florida, United States
Introduction:
Child physical abuse (CPA) remains a major cause of morbidity and mortality and presents a unique challenge for pediatric trauma centers. CPA presentations often involve an unclear or falsified history, making abused children particularly susceptible to undertriage and delayed recognition. This study applied recent consensus definitions of pediatric trauma center resource utilization (PTCRU) to characterize CPA burden of injury and evaluate undertriage/overtriage rates. The study also aimed to determine whether hospitals had potentially missed opportunities to identify children with CPA on prior encounters.
Methods:
This was a sub-analysis of injured children ≤5 years old from a multicenter pediatric trauma center registry cohort, 2021-2023. Additional data was abstracted by each center via chart review. CPA was considered positive if 1) clinical/social work teams documented suspicion for CPA, 2) a report was submitted to government child protective services (CPS), and 3) CPS launched an investigation. PTCRU criteria for CPA and non-CPA groups were compared using chi-square or Fisher's exact tests. Undertriage/overtriage rates were compared between CPA and non-CPA patients using chi-square tests. Undertrage/overtriage rates were calculated by 3 methods, Cribari, Need for Trauma Intervention (NFTI), and utilization of emergent pediatric-specific trauma center resources (e-PTCRU). Logistic regression modeling evaluated the association of CPA with evaluation at the same trauma hospital within the 3 months prior to index trauma presentation, adjusting for potential confounders.
Results:
Of the 659 children (57% male, median age 2 years) in the study cohort, 187 (28%) were deemed positive for CPA. CPA patients had higher emergent PTCRU than non-CPA patients (10% vs. 4%, p=0.001). The greatest differences in specific PTCRU criteria were seen in requiring urgent/advanced airway intervention (9% vs 3%, p=0.008), imaging under sedation/general anesthesia (13% vs. 3%, < 0.0001), direct/prolonged pediatric intensive care unit admission (27% vs. 12%, p<0.0001), and prolonged therapy or rehabilitation services (13% vs. 2%, p < 0.0001). CPA patients were more likely to be undertriaged and less likely to be overtriaged according to Cribari, NFTI, and e-PTCRU criteria (all p<0.0001). CPA patients were more likely to have been seen at the same hospital within the 3 months prior to index trauma presentation (14% vs. 5%, p=0.0002), and this association persisted after adjustment for comorbidities and age (adjusted OR 2.01, 95% CI 1.04-2.88, p=0.038).
Conclusion:
Children with CPA are high utilizers of emergent pediatric-specific trauma center resources and are frequently undertriaged. Approximately 1 in 6 children with CPA had been evaluated in the same hospital within the 3 months prior to their index trauma presentation. Future studies should refine hospital-based protocols to identify CPA, reduce undertriage, and intervene before severe injury occurs.
Comparison of undertriage and overtriage rates for physical abuse patients vs. all other mechanisms, by three different triage methods.
| | Patients with physical abuse undertriage rates | Patients with other mechanisms undertriage rates | Patients with physical abuse overtriage rates | Patients with other mechanisms overtriage rates |
| Cribari | 12.8% | 2.1% | 7.6% | 16.8% |
| NFTI | 8.1% | 1.6% | 4.1% | 15.5% |
| e-PTCRU | 4.3% | 0.6% | 16.6% | 34.5% |
p-value <0.0001 for all comparisons by chi-square tests. NFTI = need for trauma intervention; e-PTCRU = emergency pediatric trauma center resource utilization.
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