Abusive Injury Research Articles

To Sew or Not to Sew: A Case Report

Introduction-Tongue injuries in children vary from slight lacerations to complete amputations. It could be due to fall, self-mutilation, epilepsy, child abuse, or sport injury. The anterior dorsum is the most common site followed by the mid dorsum and anterior ventral part. These injuries may cause dysfunction of tongue, hemorrhage, and disfigurement. Management of injuries of tongue in young children is challenging. There are no established guidelines for managing tongue lacerations. This is a case report of a three-year-old girl with a laceration on the anterolateral part of the tongue with non-approximating wound edges. The laceration extended from the dorsal to the ventral part. The parents were apprehensive about the surgical management of the injury due to the age of their daughter. Hence, healing of the injury with conservative management without suturing was achieved. Conclusion-The management of traumatic injuries of tongue in children is difficult due to their age and cooperation. The pediatrician has to decide whether to heal the tongue by primary or secondary intention. Our decision to allow the healing by secondary intention was successful. The tongue healed without any complications barring a small scar with satisfactory aesthetic and functional outcome. Both the parents and the child were satisfied with the management of the injury.

Effects of Intimate Partner Violence-Related Strangulation on Women Who Report a Disability and Received Forensic Nursing Services.

Data on effects of strangulation in victims with a disability are lacking despite this population experiencing intimate partner violence at higher rates than women without a disability. A retrospective review was conducted on medical records of patients seeking care at a community-based, forensic nurse examiner program following an intimate partner violence-related strangulation event. The presence of disability was not associated with differences in reporting other types of victimization, additional abusive events, perpetrator characteristics, strangulation actions, or injury findings. Patients with a disability were more likely to report experiencing anoxic, hypoxic, and other physical symptoms following strangulation compared to patients without a disability.

Socioeconomic factors in inflicted traumatic brain injury: Examining the area deprivation index.

Inflicted traumatic brain injury (iTBI), or abusive head injury, is a common cause of mortality and disability among infants and toddlers. Social determinants of health (SDoH) have a critical and multifaceted impact on iTBI, influencing both prevalence and outcomes. The area deprivation index (ADI) is a comprehensive metric of SDoH developed to assist in understanding how community-level socioeconomic factors influence patient outcomes. The current study sought to describe the sociodemographic characteristics, including ADI, of a cohort of 373 infants and young children who sustained an iTBI. This study was a retrospective analysis utilizing a cohort of pediatric patients treated for iTBI at a large, tertiary care children's hospital serving seven states in the Rocky Mountain region. Mortality prevalence was higher among older children, and older children were more likely to have a longer stay in the pediatric intensive care unit. Children who were identified as Hispanic/Latino lived in areas with greater socioeconomic disadvantage than children identified as non-Hispanic/Latino. Specifically, participants who were identified as White Hispanic/Latino lived in areas with greater disadvantage than children who were identified as White non-Hispanic/Latino. There were no other significant differences by race. Contrary to hypotheses, ADI was not significantly related to mortality, injury severity, or follow-up visits. While SDoH are known to influence outcomes in iTBI, it may be necessary to incorporate individual or family-level SDoH variables within this clinical sample and examine the interaction between individual and community-level factors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Oral and Dental Aspects of Child Abuse and Neglect: Clinical Report.

In all 50 states, the District of Columbia, and the Commonwealth of Puerto Rico, pediatricians, dental professionals, and other physicians are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this clinical report is to review the oral aspects of abuse and dental neglect in children and the role of pediatricians, dental professionals, and other physicians in evaluating such conditions. This clinical report addresses recommendations on the evaluation of bite marks, as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Some physicians may have received less education pertaining to oral health, dental injury, and oral disease. These physicians may not detect the mouth and gum findings possibly related to abuse or neglect as readily as abuse injuries involving other areas of the body. Therefore, pediatricians, dental professionals, and other physicians are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children.

Red flags for child abuse : Pediatric radiological and forensic aspects

The diagnostics of physical child abuse are usually performed by amultidisciplinary team and frequently represent aclinical challenge. Radiological expertise is particularly important for the recognition of abusive injuries to the skeletal system and the central nervous system. The aim of the article is to give an overview of red flags of child abuse in radiological imaging. For the diagnostics of child abuse, conventional projection radiography of the skeletal system as well as computed tomography (CT) and magnetic resonance imaging (MRI) of the head are especially relevant. There is insufficient evidence with respect to sonography. Radiological imaging plays akey role for recognizing physical child abuse. Radiological red flags of child abuse can be crucial for making the diagnosis.

Child abuse, neglect, and non-accidental injury: challenging diagnoses in paediatric emergency and critical care.

Child abuse, neglect, and non-accidental injury: challenging diagnoses in paediatric emergency and critical care.

Deliberate Practice as an Effective Method for Reducing Diagnostic Error in Identifying Burn and Bruise Injuries Suspicious for an Abusive Injury

To examine the effectiveness of an education intervention for reducing physician diagnostic error in identifying pediatric burn and bruise injuries suspicious for abuse, and to determine case-specific variables associated with an increased risk of diagnostic error. This was a multicenter, prospective, cross-sectional study. A convenience sample of pediatricians and other front-line physicians who treat acutely injured children in the United States and Canada were eligible for participation. Using a web-based education and assessment platform, physicians deliberately practiced with a spectrum of 300 pediatric burn and bruise injury image-based cases. Participants were asked if there was a suspicion for abuse present or absent, were given corrective feedback after every case, and received summative diagnostic performance overall (accuracy), suspicion for abuse present (sensitivity), and absent (specificity). Of the 93/137 (67.9%) physicians who completed all 300 cases, there was a significant reduction in diagnostic error (initial 16.7%, final 1.6%; delta -15.1%; 95% CI 13.5, 16.7), sensitivity error (initial 11.9%, final 0.7%; delta -11.2%; 95% CI 9.8, 12.5), and specificity error (initial 23.3%, final 6.6%; delta -16.7%; 95% CI 14.8, 18.6). Based on 35,627 case interpretations, variables associated with diagnostic error included patient age, sex, skin color, mechanism of injury, and size and pattern of injury. The education intervention substantially reduced diagnostic error in differentiating the presence versus absence of a suspicion for abuse in children with burn and bruise injuries. Several case-based variables were associated with diagnostic error, and these data can be used to close specific skill gaps in this clinical domain.

Development and Evaluation of a Community Advisory Board for Family Violence.

Although intimate partner violence (IPV) is an important risk factor for child physical abuse, most IPV-exposed children are not evaluated for abusive injuries. A Community Advisory Board (CAB) was formed to (a) optimize a program to evaluate IPV-exposed children for abusive injuries and (b) inform research methods to engage IPV victims and their children. The objectives of this study were to implement and to evaluate the family violence CAB. Following best practices on CAB formation, we recruited local stakeholders with key roles as service providers, community leaders, and knowledge experts in IPV, child abuse, and emergency care. Fourteen members met bimonthly to develop a family-centered intervention and to inform research and advocacy activities. A shared memorandum of understanding outlined goals and objectives. One year after the CAB's implementation, a research assistant interviewed CAB members to understand their experiences, perceived benefits of participation, and desired improvements. Eleven CAB members, including an IPV survivor, participated. Emerging categories included (a) motivations to join the CAB (victim advocacy), (b) benefits of participation (development of relationships among members and increased acceptability of research methods), (c) facilitators of sustainability (program adaptability and development of trust), and (d) desired improvements (case-based follow-up). The CAB was successfully implemented and facilitated the development of collaborative relationships among stakeholders with key roles in IPV and child abuse. The CAB led to community member-proposed changes in research activities and clinical care for victims of IPV.

Identifying inflicted injuries in infants and young children

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Early Infantile Diagnosis of Hereditary Hemorrhagic Telangiectasia Complicated by Child Abuse

We report a rare case of hereditary hemorrhagic telangiectasia (HHT) in a 4-month-old female with findings of child abuse. She presented with poor feeding, vomiting, and irritability after a short fall from the bed. Initial evaluation found subdural hematomas (SDH), persistent hypoxia, failure to thrive (FTT), a frenulum tear, facial lacerations, and bruising. The patient was admitted and an extensive work-up led to the diagnosis of brain and pulmonary arteriovenous malformations (AVMs) and finally the diagnosis of HHT. The SDH, cutaneous injuries, and oral injury were highly suspicious for child abuse and were reported to Child Protective Services (CPS) and law enforcement for investigation simultaneous to the medical work-up. Her hospital course was complicated by progressive hypoxemia with radiographic evidence of several large pulmonary AVMs for which she underwent successful embolization. Her head injury was indeterminate for physical abuse in the setting of a medical condition pre-disposing to intracranial hemorrhage. A few weeks later, she was re-admitted with repeat abusive injuries in the form of femur fractures. This case demonstrates the unique diagnostic dilemma when two diagnoses are occurring simultaneously – HHT and child abuse – and showcases the importance of a detailed family history, genetic testing, strong multidisciplinary collaboration with a holistic approach and medically informed CPS systems to ensure accurate diagnoses and safe disposition.

Incomplete Fractures of Distal Long Bones Among Children in Early Stages of Mobility: Few Concerns for Physical Child Abuse at a Single Pediatric Level I Trauma Center.

This study aimed to describe the characteristics, reported mechanism of injury, fracture morphology, and level of physical abuse concern among children in the early stages of mobility diagnosed with an incomplete distal extremity long bone fracture. A retrospective chart review was performed for all children aged 10 to 12 months with an incomplete fracture of a distal forearm or distal lower limb who were reportedly pulling up, cruising, or ambulating, and who were evaluated by the child abuse pediatrics team at a single pediatric level I trauma center. Of the 29 patients who met inclusion criteria, the child abuse pediatrics team had concerns about physical child abuse for 3 children. Not every case with an unknown or discrepant history of injury was deemed concerning for abuse, but all 3 for whom the team determined that concern was warranted had an unknown or discrepant history. All 3 of these children had distal forearm fractures; 1 child had multiple concomitant fractures (including a scapular fracture), and 2 had evidence of bone healing at initial presentation. Each of these observations raises concern for abusive injury based on current evidence. Both-bone buckle fractures of the radius/ulna and tibia/fibula were the most common type of incomplete distal fracture. This age group presents a unique challenge when designing evidence-based algorithms for the detection of occult injuries in emergency departments. Incomplete fractures of a distal limb are commonly related to a fall and may be considered "low specificity" for physical abuse. However, some publications conclude they should prompt universal physical abuse screening. Our small study indicated that the presence or absence of certain risk factors may provide additional information which could help guide the need for a more thorough evaluation for occult injury in early-mobile children with incomplete distal extremity long bone fractures. Ongoing research is warranted.

Genital lichen sclerosus misdiagnosis: Forensic insights.

In this case study, we present an instance of genital lichen sclerosus et atrophicus that was initially misdiagnosed as child sexual abuse. A 6-year-old female presented to the emergency department with complaints of vaginal bleeding accompanied by pruritus. The initial suspicion of child abuse was prompted by the presence of blood. However, a thorough physical examination conducted by the forensic department ruled out any traumatic injuries and instead suggested an underlying pathology, ultimately diagnosed as lichen sclerosus et atrophicus. This case report underscores the vital role of forensics in excluding abuse as a cause in similar presentations, guiding the case towards a more accurate diagnosis. Additionally, it emphasizes the significance of possessing a comprehensive understanding of pathologies that can mimic abusive injuries, thereby preventing the potential consequences of an incorrect abuse diagnosis.

Variability in Occult Injury Screening Among Siblings/Household Contacts of Physical Abuse Victims.

The objective of this study is to examine radiologic occult injury screening performance/yield among contacts presenting for precautionary medical assessments and assess factors associated with deferred screening. Data were collected retrospectively from charts of contacts younger than 8 years presenting for precautionary evaluation to a level 1 pediatric emergency department January 1, 2018 to March 31, 2023. Demographics, radiologic performance/yield, physical examination, social work-based psychosocial assessment, reasons for deferred imaging, and diagnostic codes were abstracted. Descriptive statistics and χ 2 analysis are reported. Three hundred ninety contacts were identified; 364 (93.3%) were biological siblings. Most (276, 70.8%) were 2 to 8 years old. Statistically significant relationships were identified with age, insurance, and hospital social work assessment and screening. Thirty-four infants (54%) underwent neuroimaging; no studies were abnormal. Of 114 contacts, <2 years old, 97 (85%) underwent skeletal survey (SS); 9 (9%) SS were abnormal. Twenty-seven (24%) returned for follow-up SS; 4 (14.8%) were abnormal. For 2 contacts, an abnormal initial SS was refuted by follow-up imaging. Physical examinations were abnormal for 11% of contacts. Reasons for deferred imaging included contact well appearance, caregiver concerns, and clinician disagreement with indications. Encounter International Classification of Diseases codes varied, commonly reflecting nonspecific screening assessments. Despite national clinical practice guidelines, studies of abusive injury prevalence and radiologic yield among at-risk contacts exposed to unsafe environments are few. Screening evaluations inclusive of physical examination and radiologic studies identify abuse concerns among at-risk contacts. Further study of factors impacting radiologic screening decisions is needed. Considerations to advance epidemiologic research include standardized diagnostic coding and prospective assessment of radiologic yield.

Impact of the COVID-19 Pandemic on Mortality of Abusive Head Injury in Children Under One Year Old in Brazil

Impact of the COVID-19 Pandemic on Mortality of Abusive Head Injury in Children Under One Year Old in Brazil

Multiorgan Dysfunction Syndrome in Abusive and Accidental Pediatric Traumatic Brain Injury.

Abusive head trauma (AHT) is a mechanism of pediatric traumatic brain injury (TBI) with high morbidity and mortality. Multiorgan dysfunction syndrome (MODS), defined as organ dysfunction in two or more organ systems, is also associated with morbidity and mortality in critically ill children. Our objective was to compare the frequency of MODS and evaluate its association with outcome between AHT and accidental TBI (aTBI). This was a single center, retrospective cohort study including children under 3 years old admitted to the pediatric intensive care unit with nonpenetrating TBI between 2014 and 2021. Presence or absence of MODS on days 1, 3, and 7 using the Pediatric Logistic Organ Dysfunction-2 score and new impairment status (Functional Status Scale score change > 1 compared with preinjury) at hospital discharge (HD), short-term timepoint, and long-term timepointwere abstracted from the electronic health record. Multiple logistic regression was performed to examine the association between MODS and TBI mechanism with new impairment status. Among 576 children, 215 (37%) had AHT and 361 (63%) had aTBI. More children with AHT had MODS on days 1 (34% vs. 23%, p = 0.003), 3 (28% vs. 6%, p < 0.001), and 7 (17% vs. 3%, p < 0.001) compared with those with aTBI. The most common organ failures were cardiovascular ([AHT] 66% vs. [aTBI] 66%, p = 0.997), neurologic (33% vs. 16%, p < 0.001), and respiratory (34% vs. 15%, p < 0.001). MODS was associated with new impairment in multivariable logistic regression at HD (odds ratio 19.1 [95% confidence interval 9.8-38.6, p < 0.001]), short-term discharge (7.4 [3.7-15.2, p < 0.001]), and long-term discharge (4.3 [2.0-9.4, p < 0.001])]. AHT was also associated with new impairment at HD (3.4 [1.6-7.3, p = 0.001]), short-term discharge (2.5 [1.3-4.7, p = 0.005]), and long-term discharge (2.1 [1.1-4.1, p = 0.036]). Abusive head trauma as a mechanism was associated with MODS following TBI. Both AHT mechanism and MODS were associated with new impairment at all time points.

Chronic traumatic encephalopathy-neuropathologic change in a routine neuropathology service: 7-year follow-up.

To follow our 2016 study of chronic traumatic encephalopathy neuropathologic change (CTE-NC) in our forensic autopsy service, we prospectively screened all cases with clinical histories of multiple concussions, persistent post-head injury symptoms, or ≥3 hospital investigations for head injuries from 2016 to 2022 inclusive using hyperphosphorylated tau (p-tau) immunostaining. The cases had routine brain sampling plus 4-6 additional lateral hemisphere samples. When "pathognomonic" CTE-NC lesions were identified, additional p-tau immunostaining was done for CTE-NC staging. Of ∼1100 adult brains aged 18-65 years examined, 85 were screened, and 16 were positive for CTE-NC (2 women, 14 men, ages 35-61 years, median 47 years). Alcohol abuse was documented in 14 of 16 (8 in combination with other substances); 5 had developmental brain anomalies (2 presumed genetic, 3 from acquired perinatal insults). Widespread p-tau deposits (high CTE-NC) were found in 7 of 16. Old brain contusions were present in 9 of 16, but CTE-NC did not colocalize. Of particular interest were (1) a man with FGFR3 mutation/hypochondroplasia and life-long head banging, (2) a woman with cerebral palsy and life-long head banging, and (3) a man with bilateral peri-Sylvian polymicrogyria, alcohol abuse, and multiple head injuries. Thus, CTE-NC occurs in association with repeated head trauma outside contact sports. Substance abuse is a common determinant of risk behavior. The utility of diagnosing mild-/low-stage CTE-NC in this population remains to be determined.

Social determinants of health in pediatric trauma: Associations with injury mechanisms and outcomes in the context of the COVID-19 pandemic

BackgroundRelationships between social determinants of health and pediatric trauma mechanisms and outcomes are unclear in context of COVID-19. MethodsChildren <16 years old injured between 2016 and 2021 from ten pediatric trauma centers in Florida were included. Patients were stratified by high vs. low Social Vulnerability Index (SVI). Injury mechanisms studied were child abuse, ATV/golf carts, and firearms. Mechanism incidence trends and mortality were evaluated by interrupted time series and multivariable logistic regression. ResultsOf 19,319 children, 68% and 32% had high and low SVI, respectively. Child abuse increased across SVI strata and did not change with COVID. ATV/golf cart injuries increased after COVID among children with low SVI. Firearm injuries increased after COVID among children with high SVI. Mortality was predicted by injury mechanism, but was not independently associated with SVI, race, or COVID. ConclusionSocial vulnerability influences pediatric trauma mechanisms and COVID effects. Child abuse and firearm injuries should be targeted for prevention.

Frequency of injuries in a voluntary program evaluating young children exposed to intimate partner violence

ObjectiveIntimate partner violence (IPV) affects 1 in 4 American women, and physical child abuse is reported to occur in 10–67 % of homes with IPV. Routine evaluation of physical abuse in IPV-exposed children is neither widespread nor informed by clinical guidelines. Thus, the true frequency of detectable injuries in IPV-exposed children remains unknown. The purpose of this study was to examine the frequency of injuries in children <3-years-old reported for IPV to a regional child protective services (CPS) office. MethodsIn this prospective observational study, we reviewed encounters of children whose caregivers agreed to an evaluation for injuries (physical exam and imaging, if indicated) from July 2019–June 2022. Children were included if: 1) a CPS investigator referred a child for evaluation for injuries (“non-acute” evaluation) or 2) a child presented immediately after an IPV incident (“acute” evaluation). ResultsOf 326 children <3-years-old reported to the CPS office after IPV exposure, 90 (27.6 %) were evaluated: 81(90 %) presented for a non-acute evaluation, and 21(23 %) were reported to have sustained trauma during the IPV event. Of the 90 children evaluated, 3 (3.3 %, 95 % CI 0.7–9.4) were found to have cutaneous injuries, fractures, and/or intracranial findings. Each was <6-months old and had an “acute” evaluation. ConclusionIn this study of children reported to CPS for IPV exposure, a small percentage was found to have injuries. A multi-center study that examines the frequency of and factors that increase the risk of abusive injuries in IPV-exposed children may ensure that testing targets children at highest risk.

Immune microenvironment changes of liver cirrhosis: emerging role of mesenchymal stromal cells.

Cirrhosis is a progressive and diffuse liver disease characterized by liver tissue fibrosis and impaired liver function. This condition is brought about by several factors, including chronic hepatitis, hepatic steatosis, alcohol abuse, and other immunological injuries. The pathogenesis of liver cirrhosis is a complex process that involves the interaction of various immune cells and cytokines, which work together to create the hepatic homeostasis imbalance in the liver. Some studies have indicated that alterations in the immune microenvironment of liver cirrhosis are closely linked to the development and prognosis of the disease. The noteworthy function of mesenchymal stem cells and their paracrine secretion lies in their ability to promote the production of cytokines, which in turn enhance the self-repairing capabilities of tissues. The objective of this review is to provide a summary of the alterations in liver homeostasis and to discuss intercellular communication within the organ. Recent research on MSCs is yielding a blueprint for cell typing and biomarker immunoregulation. Hopefully, as MSCs researches continue to progress, novel therapeutic approaches will emerge to address cirrhosis.

Orofacial manifestations of child maltreatment: A review.

The recognition and reporting of child abuse and neglect continues to be a challenge in the healthcare setting. All healthcare providers, including dentists, should be aware of the high prevalence of orofacial injuries and conditions that are concerning for abuse and neglect. Sentinel injuries may appear trivial and do not require medical attention, but are unlikely caused by accidental mechanisms and, if not properly identified, often precede more severe abusive injuries. Concerning orofacial findings can manifest as bruising, eye injuries, intraoral injuries, pharyngeal perforations, facial bone fractures, and sexually transmitted infections. Abusive caregivers are likely to give inadequate explanations or no history at all to explain concerning findings. Medical providers' failure to make mandated reports about their concerns to the appropriate agencies can have significant long-term impacts on the physical and psychological well-being of children.