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OBJECTIVE: Routine testing of hepatic transaminases, amylase, and lipase has been recommended for all children evaluated for physical abuse, but rates of screening are widely variable, even among abuse specialists, and data for amylase and lipase testing are lacking. A previous study of screening in centers that endorsed routine transaminase screening suggested that using a transaminase threshold of 80 IU/L could improve injury detection. Our objectives were to prospectively validate the test characteristics of the 80-IU/L threshold and to determine the utility of amylase and lipase to detect occult abdominal injury. METHODS: This was a retrospective secondary analysis of the Examining Siblings To Recognize Abuse research network, a multicenter study in children younger than 10 years old who underwent subspecialty evaluation for physical abuse. We determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing. Screening studies were compared by using basic test characteristics (sensitivity, specificity) and the area under the receiver operating characteristic curve. RESULTS: Abdominal injuries were identified in 82 of 2890 subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for amylase and lipase were 0.67 and 0.72, respectively. CONCLUSIONS: Children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old. RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts. [ABSTRACT FROM AUTHOR]

The article discusses ways to improve clinical judgment in cases that involve child abused. Topics discussed include the 1962 publication of "The Battered Child Syndrome, " by Kempe and colleagues, the paper "Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma," by Berger and colleagues, and the use of clinical prediction rule (CPR) in aiding either the diagnosis or prognosis of clinical conditions.

Objective: Follow-up skeletal surveys (FUSS) are performed frequently in cases of possible physical abuse based on the evidence from small retrospective cohorts. Our objective was to determine the proportion of FUSS that identified new information in a large, multicenter population of children with concerns of physical abuse., Methods: This was a prospective secondary analysis of an observational study of all children <10 years of age (120 months) who underwent evaluation for possible physical abuse by 20 US child abuse teams. This analysis included all children in whom FUSS was recommended and measured rates of FUSS completion, results of FUSS, and the change in perceived likelihood of abuse before and after FUSS., Results: Among 2890 children enrolled in the Examining Siblings To Recognize Abuse research network, 2049 underwent skeletal survey and 796 (38.8%) had FUSS. A total of 174 (21.5%) subjects had new information identified by FUSS, including 124 (15.6%) with at least 1 new fracture and 55 (6.9%) with reassuring findings compared with the initial skeletal survey. Among cases with new fractures, the estimated likelihood of abuse increased in 41 (33%) cases, and 51 cases (41%) remained at the maximum likelihood of abuse., Conclusions: FUSS identified new information and affected the perceived likelihood of abuse in a substantial fraction of cases in which it was completed. These data support existing guidelines and, in addition, suggest that FUSS should be considered in cases with lower initial levels of concern for abuse.