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Child Abuse

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The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation.
Escobar MA Jr, Flynn-O'Brien KT, Auerbach M, Tiyyagura G, Borgman MA, Duffy SJ, Falcone KS, Burke RV, Cox JM, Maguire SA.
J Trauma Acute Care Surg. 2017 Jun;82(6):1147-1157.

Rationale for inclusion: The Pediatric Trauma Society (PTS) Guidelines Committee Non-Accidental Trauma (NAT) Group published their manuscript “The association of non-accidental trauma with historical factors, exam findings and diagnostic testing during the initial trauma evaluation” in the Journal of Trauma and Acute Care Surgery. The Guideline Committee identified screening for NAT as a key area for guideline development during the first annual PTS meeting when a number of presentations on guidelines were noted to have significant variations across centers. A multi-disciplinary working group was created including PTS members and international experts in NAT from outside of PTS. Subgroups were developed to summarize and assess the quality of the evidence describing the correlation between NAT and the following: bruising, burns, abusive head trauma [AHT], abdominal injuries, fractures, historical factors, and oral trauma. The groups approach was novel in that it focused on these seven specific findings and the likelihood that each alone might be a harbinger of NAT. Over the subsequent two years the group synthesized the highest-quality evidence for each of these findings to be presented in one publication. The associations with NAT were summarized in a table within the article (attached). The authors believe that this table provides a one-page resource for use by ED, traumatologists, and emergency personnel that encapsulate key findings or "satchel knowledge."

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Derivation of a clinical prediction rule for pediatric abusive head trauma.
Hymel KP, Willson DF, Boos SC, Pullin DA, Homa K, Lorenz DJ, Herman BE, Graf JM, Isaac R, Armijo-Garcia V, Narang SK; Pediatric Brain Injury Research Network (PediBIRN) Investigators.
Pediatr Crit Care Med. 2013 Feb;14(2):210-20.

Rationale for inclusion: PEDIBIRN clinical prediction rule is a 4-variable applied to hospitalized patients in the pediatric intensive care unit with intracranial injury on CT or MRI, confirmed as AHT or nAHT. Found to be 96% sensitive, 43% specific for abusive head trauma (AHT) in this patient population with 1+ feature* in child < 3 years. *Acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture.

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Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review.
Maguire SA, Watts PO, Shaw AD, Holden S, Taylor RH, Watkins WJ, Mann MK, Tempest V, Kemp AM.
Eye (Lond). 2013 Jan;27(1):28-36.

Rationale for inclusion: The authors performed a systematic review to report the retinal findings that distinguish AHT from non-abusive head trauma (nAHT). Hospitalized children ages 0-11 with head injury diagnosed on CT or MRI with performance of an eye exam by an ophthalmologist were included. In a child with head trauma and retinal hemorrhages, the OR that the injury was AHT was 14.7 (95% confidence intervals 6.39 - 33.62) and the probability of abuse was 91%. Certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, but there was no retinal sign that was unique to abusive injury. RH were rare in accidental trauma and, when present, were predominantly unilateral, few in number and in the posterior pole.

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Estimating the probability of abusive head trauma: a pooled analysis.
Maguire SA, Kemp AM, Lumb RC, Farewell DM.
Pediatrics. 2011 Sep;128(3):e550-64.

Rationale for inclusion: PredAHT clinical prediction rule is a CPR based on combinations of six clinical features in hospitalized patients with intracranial injury, confirmed as AHT or nAHT. When ≥ 3 features** were present in children < 3 years with intracranial injury: Sensitivity: 72.3% (95% CI 60.4-81.7); Specificity: 85.7% (95% CI 78.8-90.7). ** Retinal hemorrhage, rib and long-bone fractures, apnea, seizures, and head or neck bruising.

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Bruising characteristics discriminating physical child abuse from accidental trauma.
Pierce MC, Kaczor K, Aldridge S, O'Flynn J, Lorenz DJ.
Pediatrics. 2010 Jan;125(1):67-74.

Rationale for inclusion: The authors sought to identify distinguishing features of abusive and non-abusive bruising characteristics in children, and to create a decision rule to predict abusive trauma based on bruising patterns. This resulted in the classic TEN-4 rule. Body region(s), abused vs. non-abused children: In children <=4 years of age - Torso (chest, abdomen, back, buttocks, genitourinary region, hip) – 77 vs. 6; Ears – 8 vs. 0; Neck – 18 vs. 0; Total for TEN region: 103 bruises in 25 abused children vs. 6 bruises in 6 non-abused children. In infants < 4months - Any region; Total: 74 bruises in 14 abused children vs. 13 bruises in 7 non-abused children. Clinical prediction rule based on TEN-4 (regions and age):  bruising in children < 4 years on trunk, ears, neck; or any bruising in infants < 4 month: 97% Sensitivity; 84% Specificity.

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Analysis of missed cases of abusive head trauma.
Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC.
JAMA. 1999 Feb 17;281(7):621-6.

Rationale for inclusion: The diagnosis of child abuse can be challenging and the consequences of missing the diagnosis can be lethal.  This study evaluates children with a missed diagnosis of abusive head trauma.  In these children, it took seven days to arrive at the correct diagnosis. Over 1/4 of these children were re-injured during that time, and 40% had medical complications related to the missed diagnosis.  Of the five children who died, four of these deaths were preventable if child abuse had been recognized sooner. This paper serves as a clarion call to the healthcare community to have a low threshold for evaluation of potential child abuse, given the potentially devastating consequences of missing this diagnosis. 

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Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Am J Prev Med. 1998 May;14(4):245-58.

Rationale for inclusion: This study evaluated exposure to adverse events in childhood and the relationship to adult health.  It identified a graded "dose response" relationship between adverse events in childhood (physical abuse, sexual abuse, emotional abuse) and causes of death in adulthood (ischemic heart disease, cancer, lung disease, liver disease, etc.). This study highlights the potentially widespread, lifetime benefits to prevention and treatment of child abuse. 

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Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS.
Am J Prev Med. 1998 May;14(4):245-58.

Rationale for inclusion: *Acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture.

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Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial.
Olds DL, Eckenrode J, Henderson CR Jr, Kitzman H, Powers J, Cole R, Sidora K, Morris P, Pettitt LM, Luckey D.
JAMA. 1997 Aug 27;278(8):637-43.

Rationale for inclusion: Long term follow up to a prospective randomized trial to prevent child abuse demonstrates beneficial effects to families fifteen years later.  The intervention of home visits by a nurse prenatally and through the first two years correlated with decreased child abuse and neglect, decreased number of subsequent pregnancies, decreased use of welfare, decreased substance abuse, and decreased criminal behavior.

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Preventing child abuse and neglect: a randomized trial of nurse home visitation.
Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R.
Pediatrics. 1986 Jul;78(1):65-78.

Rationale for inclusion: A rare prospective randomized trial in child abuse examined the intervention of home visitation by a nurse during the prenatal and infant time periods.  During these two years, children in the intervention group had fewer instances of abuse and neglect, fewer ED visits, and fewer accidents and poisonings.  This study demonstrates that effective prevention of child abuse is possible and has meaningful benefits. 

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Preventing child abuse and neglect: a randomized trial of nurse home visitation.
Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R.
Pediatrics. 1986 Jul;78(1):65-78.

Rationale for inclusion: The authors ultimately posit this 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.

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The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation.
Caffey J.
Pediatrics. 1974 Oct;54(4):396-403.

Rationale for inclusion: The injury mechanism of common infant nonaccidental trauma is first described in this paper.  It identifies shaking rather than blunt battering as the cause of subdural hematoma, ocular hemorrhage, and brain injury. It clarifies how severely injured infants may not have significant external findings of trauma. This paper was important in dispelling the notion of a "spontaneous" subdural hematoma in infants. 

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The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation.
Caffey J.
Pediatrics. 1974 Oct;54(4):396-403.

Rationale for inclusion: The injury mechanism of common infant non-accidental trauma is first described in this paper.  It identifies shaking rather than blunt battering as the cause of subdural hematoma, ocular hemorrhage, and brain injury. It clarifies how severely injured infants may not have significant external findings of trauma. This paper was important in dispelling the notion of a "spontaneous" subdural hematoma in infants. 

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

The battered-child syndrome.
Kempe CH, Silverman FN, Steele BF, Droegemueller W, Silver HK.
JAMA. 1962 Jul 7;181:17-24.

Rationale for inclusion: Kempe's paper is the first to describe the medical manifestations of non-accidental trauma.  The authors coined the phrase "battered child syndrome" to characterize the constellation of findings including childhood fractures, subdural hematoma, soft tissue swelling, skin bruising, failure to thrive, and sudden death. They highlight the importance of injury that does not correlate to the described history. This early paper remains compelling and foresightedly contemporary.

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The battered-child syndrome.
KEMPE CH, SILVERMAN FN, STEELE BF, DROEGEMUELLER W, SILVER HK.
JAMA. 1962 Jul 7;181:17-24.

Rationale for inclusion: Kempe's paper is the first to describe the medical manifestations of nonaccidental trauma.  The authors coined the phrase "battered child syndrome" to characterize the constellation of findings including childhood fractures, subdural hematoma, soft tissue swelling, skin bruising, failure to thrive, and sudden death. They highlight the importance of injury that does not correlate to the described history. This early paper remains compelling and foresightedly contemporary.

Citations  - To review the number of citations for this landmark paper, visit Google Scholar.

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