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Physicians recommend elements to look for in suspected child physical abuse evaluations

A panel of child abuse pediatricians recently convened to establish guidelines on evaluation of suspected physical abuse among children presenting with intracranial hemorrhage, long bone fracture or isolated skull fracture.

“Every year, health care providers in the United States report more than 150,000 children to local Child Protective Services agencies. More than 4,500 children are hospitalized with injuries due to physical abuse every year,” study researcher Kristine A. Campbell, MD, MSc, of the University of Utah, and colleagues wrote. “Medical evaluation of suspected child physical abuse presents a unique challenge to physicians, requiring consideration of a broad differential, attention to detailed injury history, testing for occult injury, and difficult questions related to social risk factors often overlooked in the setting of acute trauma.”

To define critical elements for the medical evaluation of suspected physical abuse among children aged 0 to 60 months, 28 child abuse pediatricians from two national organizations formed an expert panel that participated in a Delphi Process. Physicians rated the importance of patient demographics, history of present illness, past medical, family and social history, laboratory, radiology and consultation elements via surveys. They then discussed survey results over three separate meetings. Elements rated an 8 or 9 on a 9-point scale by at least 75% of the panel were considered required and highly recommended.

Of the 96 elements included in initial surveys, the panel identified 30 required elements and 37 highly recommended elements for child abuse pediatrician evaluation of intracranial hemorrhage, 21 required and 31 highly recommended elements for evaluation of long bone fracture, and 18 required and 16 highly recommended elements for evaluation of isolated skull fracture.

Required and highly recommended elements regarding historical information, laboratory studies and radiologic examinations identified by the panel are consistent with current published guidelines, according to researchers.

However, the panel did diverge from current guidance regarding the identification of psychosocial elements. Few elements of social history were considered required for evaluation. Descriptions of caregiver mental health, substance abuse, pregnancy planning and parent perceptions of child temperament or behavior were not requirements for evaluation, according to panelists, despite being current practice recommendations.

This is because panelists worried these psychosocial elements may lead to bias. The final guideline acknowledges the uncertainty panelists felt about the reliability of psychosocial factors in shaping early diagnostic decisions.

“As a new subspecialty, [child abuse pediatric] providers have a unique opportunity to define appropriate practices that best balance the goals of traditional pediatrics with the emerging expectations of forensic evaluation,” Campbell and colleagues wrote. “These consensus guidelines may provide a useful starting point for development of a checklist child abuse assessment protocol for quality improvement or research efforts in the future.” – by Amanda Oldt

Disclosure: The researchers report no relevant financial disclosures.