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Child physical abuse is a leading cause of traumatic injury and death in children. In 2017, child abuse was responsible for 1688 fatalities in the United States, of 3.5 million children referred to Child Protection Services and 674,000 substantiated victims. While large referral hospitals maintain teams trained in Child Abuse Pediatrics, smaller community hospitals often do not have such dedicated resources to evaluate patients for potential abuse. Moreover, identification of abuse has a low margin of error, as false positive identifications lead to unwarranted separations, while false negatives allow dangerous situations to continue. This context makes the consistent detection of and response to abuse difficult, particularly given subtle signs in young, non-verbal patients. Here, we describe the development of artificial intelligence algorithms that use unstructured free-text in the electronic medical record—including notes from physicians, nurses, and social workers—to identify children who are suspected victims of physical abuse. Importantly, only the notes from time of first encounter (e.g.: birth, routine visit, sickness) to the last record before child protection team involvement were used. This allowed us to develop an algorithm using only information available prior to referral to the specialized child protection team. The study was performed in a multi-center referral pediatric hospital on patients screened for abuse within five different locations between 2015 and 2019. Of 1123 patients, 867 records were available after data cleaning and processing, and 55% were abuse-positive as determined by a multi-disciplinary team of clinical professionals. These electronic medical records were encoded with three natural language processing (NLP) algorithms—Bag of Words (BOW), Word Embeddings (WE), and Rules-Based (RB)—and used to train multiple neural network architectures. The BOW and WE encodings utilize the full free-text, while RB selects crucial phrases as identified by physicians. The best architecture was selected by average classification accuracy for the best performing model from each train-test split of a cross-validation experiment. Natural language processing coupled with neural networks detected cases of likely child abuse using only information available to clinicians prior to child protection team referral with average accuracy of 0.90±0.02 and average area under the receiver operator characteristic curve (ROC-AUC) 0.93±0.02 for the best performing Bag of Words models. The best performing rules-based models achieved average accuracy of 0.77±0.04 and average ROC-AUC 0.81±0.05, while a Word Embeddings strategy was severely limited by lack of representative embeddings. Importantly, the best performing model had a false positive rate of 8%, as compared to rates of 20% or higher in previously reported studies. This artificial intelligence approach can help screen patients for whom an abuse concern exists and streamline the identification of patients who may benefit from referral to a child protection team. Furthermore, this approach could be applied to develop computer-aided-diagnosis platforms for the challenging and often intractable problem of reliably identifying pediatric patients suffering from physical abuse.

Background Laboratory evaluation is commonly integrated into evaluation of children with suspected physical abuse to identify occult injury and potential mimics of abuse, including hemophagocytic lymphohistiocytosis (HLH). We evaluated the utility of ferritin in laboratory screening panels for physical abuse. Objective(s) To determine if hyperferritinemia is a useful screening marker of HLH in physical abuse diagnostic evaluations. Participants and setting Children being evaluated for physical abuse at a quaternary pediatric referral and level one trauma center in Houston, Texas. Methods We conducted a 12-year (2003 – 2015) retrospective descriptive analysis of all ferritin values obtained as part of routine screening panels for physical child abuse. Medical records were abstracted for patients with ferritin > 500 ng/mL. Results 2954 ferritin levels were obtained in 3091 encounters for suspected physical abuse (median age 6.5 months, interquartile range 2.3–23.5 months). Elevated ferritin was found in 82/2954 (2.8 %); no child evaluated for physical abuse was found to have HLH (95 % CI: 0–4.5%). The child abuse team was consulted in 48/82 (58.5 %) of cases, with the final impression being physical abuse in 33/48 (68.8 %). Conclusions We found no instances where HLH was identified by institutional screening panels. The inclusion of ferritin in the screening panel was not beneficial. The presence of hyperferritinemia should not cast medical or legal doubt on physical abuse diagnoses when there is a high index of clinical suspicion. Novel hypotheses from case reports and case series should be studied more rigorously before affecting system change.

This study's purpose is to evaluate whether bone speed of sound (SOS) data, a parameter of quantitative ultrasound, collected from an infant autopsy sample are comparable to data collected from healthy, living infants. We hypothesize that SOS values obtained from deceased term-born infants will fall within the normal range for healthy, living infants. The study sample consists of 351 deceased infants between the ages of 30 weeks gestation at birth to 1 year postnatal at the time of death receiving autopsies at the Harris County Institute of Forensic Sciences or Texas Children's Hospital in Houston, TX. Various multivariate and univariate statistics were used to examine the relationship between SOS and age, prematurity, and chronic illness. The results of an ANOVA comparing the study sample data to published data from healthy, living infants indicate the SOS data are comparable. Additionally, a MANOVA indicated significant differences in SOS related to prematurity (p = 0.001) and age (p < 0.001). Mean SOS was significantly greater among term-born infants (M = 3065.66, SD =165.05) than premature infants (M = 2969.71, SD =192.72). Age had a significant polynomial (cubic) relationship with SOS for both the premature and term groups (p < 0.001). Results suggest that bone from an infant autopsy sample is an appropriate surrogate to examine the relationship between SOS and determinants of bone strength. Therefore, future research will use this study sample to investigate the relationship between SOS and determinants of bone strength in infants.

Background Distinct patterns of retinal hemorrhages (RHs) are suggestive of abusive head trauma in the context of unexplained intracranial injury. Current recommendations encourage an eye examination within 48 hours of admission due to the rapid resolution of RH. The purpose of this study was to identify clinical factors associated with a delay in funduscopic examination outside the recommended 48 hours. Methods Retrospective chart review was completed on all inpatient consultations by the Child Protection Team with evidence of intracranial injury on computed tomography or magnetic resonance imaging over 3 years at a large children's hospital. Extracted data included demographic characteristics, history of intubation, pediatric intensive care unit (PICU) admission, extraventricular drain placement, seizures, use of vasopressor support, and presence of other injuries. Descriptive statistics were used to describe the patient population, clinical characteristics, and outcomes. Multivariate logistic regression was used to identify factors associated with delayed eye examinations. Results A total of 203 patients met inclusion criteria. Of those, 39 (19.2%) had a delay in initial funduscopic examination. Multivariate analyses revealed that PICU admission, surgical intervention, and seizure activity were significant predictors of delayed examination after controlling for multiple clinical factors. Neurosurgical consultation was shown to be protective against a delayed examination. Conclusions Rapid resolution of RH may occur in child abuse. Prompt ophthalmology examinations and neurosurgery consultation when child abuse is suspected help avoid a delay in diagnosis.

While various forms of facial trauma, bruising, burns, and fractures are frequently seen in cases of child abuse, purposeful nasal erosion has rarely been identified as a form of abusive injury. Progressive destruction of nasal tissue in children provokes a wide differential diagnosis crossing multiple subspecialties: infectious, primary immunodeficiencies, inflammatory conditions, malignancy, and genetic disorders. Progressive nasal erosion also can be a manifestation of child abuse. The proposed mechanism is repetitive mechanical denudation of the soft tissue and cartilage resulting in chronic inflammation, bleeding, and ultimately destruction of the insulted tissue. We report 6 cases of child abuse manifesting as overt nasal destruction.

We describe 3 infants with skull fractures that involved more than 1 skull bone. On further evaluation, 2 of the 3 infants had additional fractures at other sites of the body and the third infant had concerning bruising of the face. Although an accidental mechanism of injury was initially given as the history in each case, law enforcement investigations led all 3 fathers to confess to crushing their infants' skulls out of frustration. These crushes were caused by their arms or hands. Bilateral skull fractures or those involving more than 1 skull bone can be seen in falls as well as in crush injuries. A crush-like pattern of injury, in the absence of a clear and plausible accidental mechanism, should raise concerns for possible physical abuse especially in nonambulatory infants.

OBJECTIVES: Hospitalizations for child maltreatment cases are longer and costlier than hospitalizations for medically similar nonabuse cases. Some discharges are delayed despite medical clearance because of a lack of safe disposition, increasing the cost of hospitalization. We aim to quantify the additional charges and costs of these delays. METHODS: A retrospective chart review evaluated the dates of medical clearance and clinical characteristics of child protection team inpatient consults from 2012 to 2014 at a 595-bed quaternary-care urban hospital. Charges and costs were compared between those with no delay, those with any delay, and those with a delay >1 day. We excluded children who were not admitted, in whom no abuse was suspected, or in whom sexual abuse was suspected absent extragenital injury. RESULTS: Thirty-six percent (134 of 375) of children hospitalized for abuse remained hospitalized after medical clearance and 20.5% (77 of 375) of children were delayed >1 day. Among those who were delayed, the mean number of days delayed was 4.37 (SD ±7.44). Mean charges after medical clearance were $13 647.53 (±$30 172.17), and mean costs after medical clearance were $6521.93 (±$13 975.34). Both charges and costs were markedly right-skewed. Median costs after medical clearance were $1553.64 (interquartile range, $26.10–$5244.20). Cumulatively, 586 total days of delay resulted in excess charges of $1.8 million. CONCLUSIONS: Continued hospitalization beyond medical clearance occurs often and represents a significant cost. Further study is needed to evaluate whether interventions can be targeted at children with characteristics correlated with prolonged discharge delays.

In 2012, the Harris County Institute of Forensic Sciences began prospectively collecting injury data from pediatric autopsies. These data and associated case information from 635 pediatric cases are archived in the Infant Injury Database (IID). This paper introduces the IID to the forensic community and demonstrates its potential utility for child abuse and infant fatality investigations. The database is intended to be a source of evidence-based research for coroners/medical examiners and clinicians in the recognition and diagnosis of child abuse. RR estimates were employed to quantify the relationship between individual autopsy findings to trauma-related and nontrauma-related causes of death. For example, unsurprisingly, the RR of trauma cases with multiple injury types is significantly greater than other causes of death, but the RR results provide a quantitative representation of the relationship. ROC curve modeling of the presence/absence of various injury types performed well at discriminating trauma from other causes of death (AUC = 0.96).

Background:The genitalia examination and collection of forensic evidence are essential components of the medical evaluation when sexual abuse is suspected. In addition to a complete history/interview, the medical visit for a suspected child sexual abuse victim usually includes a detailed examination of external genitalia and anus as well as, if indicated, the collection of forensic evidence. It is important that medical and nursing professionals are able to correctly identify normal genital and anal structures before they can identify abnormal physical findings in either the prepubertal or adolescent patient. Additionally, medical and nursing professionals are expected to accurately collect and preserve forensic evidence when possible.Methods:A topical review of literature that examines: 1) if physicians and nurse practitioners could identify basic anatomic structure of external genitalia, and 2) the timing and yield of forensic evidence collection kits.Results:Physicians vary in their ability to correctly identify prepubertal genital anatomic structures. Over a series of studies, on the same photograph of female prepubertal genitalia, 59 to 64% of physicians correctly identified the hymen from; 76 to 90% correctly identified the labia minora, and 63 to 78%correctly identified the urethra. On a second photo, deemed more clear, 71% of pediatric chief residents correctly labeled the hymen. Pediatric nurse practitioners performed similarly to the physicians correctly identifying the hymen 59%, labia minora 88% and urethra 81%. Looking at photographs of male prepubertal genitalia, 93% of pediatric chief residents correctly identified the basic structures while only 22% correctly recognized hypospadias. Literature reviewed on forensic evidence collection kits support an extended window for evidence collection of up to 96 hours after suspected sexual contact especially of clothing and other non-body surfaces.Conclusion:Medical and advanced practice nursing professions have to improve the educational processes of clinicians who evaluate and treat children suspected of abuse. Physicians and nurse practitioners experienced difficulty in correctly labeling and identifying basic external genital structures on a photograph of a prepubertal child’s genitalia. Additionally, extending the time frame from suspected sexual contact to examination to a window of up to 96-hours post assault may increase the yield of recovering forensic evidence in both pre and post-pubertal patients.

Young children with suspected abusive head trauma often receive skull radiographs to evaluate for fractures as well as computed tomography (CT) of the head to assess for intracranial injury. Using a CT as the primary modality to evaluate both fracture and intracranial injury could reduce exposure to radiation without sacrificing performance. To evaluate the sensitivity of CT head with (3-D) reconstruction compared to skull radiographs to identify skull fractures in children with suspected abusive head trauma. This was a retrospective (2013-2014) cross-sectional study of infants evaluated for abusive head trauma via both skull radiographs and CT with 3-D reconstruction. The reference standard was skull radiography. All studies were read by pediatric radiologists and neuroradiologists, with ten percent read by a second radiologist to evaluate for interobserver reliability. One hundred seventy-seven children (47% female; mean/median age: 5 months) were included. Sixty-two (35%) had skull fractures by radiography. CT with 3-D reconstruction was 97% sensitive (95% confidence interval [CI]: 89-100%) and 94% specific (CI: 87-97%) for skull fracture. There was no significant difference between plain radiographs and 3-D CT scan results (P-value = 0.18). Kappa was 1 (P-value

Long bone fractures at the infant growth plate, known as classic metaphyseal lesions (CMLs), raise a strong suspicion for abusive injury. CMLs persist as a hallmark for inflicted injury although a handful of documented cases of CMLs created by other, non-abusive mechanisms within various healthcare settings are scattered throughout the past few decades of medical literature. The forces required to sustain a CML are typically defined as a combination of tensile, compressive, or rotational energy applied to the metaphyseal regions of an infant's long bones. Recently, two separate child protection teams each encountered a case of CML discovered after reported motor vehicle collisions (MVC). This provoked a critical appraisal of the medical literature to inform clinical practice regarding MVCs as a potential mechanism for this fracture type and to remind clinicians that there is no single injury pathognomonic for abuse.

Pediatric rib head fractures are typically described as "posterior" or "costovertebral," terms lacking specificity. To resolve this issue, a scheme was developed to describe the location of rib head fractures observed in a pediatric forensic population. The scheme uses three anatomical landmarks, terminus (tip), tubercle, and costovertebral articular surface to divide the rib head into two subregions, costovertebral and costotransverse. Examples of five cases of infants with rib head fractures are presented using this scheme. Forty-eight rib head fractures were observed in these infants with the following frequencies: 56% (three infants) at the terminus; 21% (three infants) in the costovertebral subregion; 21% (one infant) at the costovertebral articular facet; and 2% (one infant) in the costotransverse subregion. Due to the small number of cases assessed, statistical analyses could not be performed; however, the data demonstrate the variation in distribution of pediatric rib head fractures.

The literature pertaining to pediatric skull fracture is primarily clinically based and thus motivated by the need for effective assessment of both fracture characteristics (type, frequency, location, and mechanics) and context (severity of injury, associated soft tissue damage, and prognosis). From a strictly descriptive standpoint, these schemas employ overlapping levels of detail that confound the nonclinical description of fractures in the forensic context. For this reason, application of these schemas in the forensic anthropological interpretation of skull fractures is inappropriate. We argue that forensic anthropological interpretation of skull fractures requires a standard classification system that reflects fracture morphology alone, and we suggest a three-stepped classification system that conveys increasing detail with each additional step. A retrospective application of the method to a sample of 31 children aged 1 month to 2 years demonstrated its efficacy in the description of pediatric skull fractures. Language: en

In infants and children with fractures from an unclear cause, osteogenesis imperfecta (OI) is often included as a potential etiology. In infants and children with OI there exists a gap in the published literature regarding the fracture pattern seen at the time of diagnosis. As an additional aid to the diagnosis of OI, we sought to characterize the fracture patterns in infants and children at the time of their diagnosis.We performed a retrospective chart review of a series of infants and children under 18 years of age who have the diagnosis of OI (any type) from a single institution.We identified 68 infants and children with OI: 23 (34%) type 1, 1 (2%) type 2, 17 (25%) type 3, 24 (35%) type 4, and 3 (4%) unknown type. A family history of OI was present in 46% of children. Forty-nine (72.0%) patients were diagnosed solely on clinical characteristics, without genetic or fibroblast confirmation. Rib fractures were noted in 21% of the subjects with none being identified during infancy. The number of fractures identified at diagnosis ranged from 1 to37 with 7 (10%) having more than 2 fractures. All subjects with more than 2 fractures were diagnosed prenatally or in the immediate newborn period. Seventeen (25%) infants were diagnosed after 1 week of age but before 12 months of age. None of these infants had either rib fractures or more than 1 fracture at the time of diagnosis.The majority of children diagnosed with OI are diagnosed by clinical features alone. The fracture pattern at the time of diagnosis in OI is variable with 10% having more than 2 fractures. The diagnosis of OI was made in utero or at delivery in 43% of children. Multiple rib fractures in an infant would be an unexpected finding in OI.Level III.

It is common to evaluate children who have sustained minor head trauma with computed tomography (CT) of the head. Scalp swelling, in particular, has been associated with intracranial injury. A subset of patients, however, present in delayed fashion, often days after the head trauma, as soft tissue edema progresses and their caregiver notices scalp swelling. We explore the value of further workup in this setting.We conducted a retrospective review of a prospectively collected cohort of children ≤24 months of age presenting to the Texas Children's Hospital with scalp swelling more than 24 h following a head trauma. Cases were collected over a 2-year study period from June 1, 2014 to May 31, 2016.Seventy-six patients comprising 78 patient encounters were included in our study. The mean age at presentation was 8.8 months (range 3 days-24 months). All patients had noncontrast CT of the head as part of their evaluation by emergency medicine, as well as screening for nonaccidental trauma (NAT) by the Child Protection Team. The most common finding on CT head was a linear/nondisplaced skull fracture (SF) with associated extra-axial hemorrhage (epidural or subdural hematoma), which was found in 31/78 patient encounters (40%). Of all 78 patient encounters, 43 patients (55%) were discharged from the emergency room (ER), 17 patients (22%) were admitted for neurologic monitoring, and 18 patients (23%) were admitted solely to allow further NAT evaluation. Of those patients admitted, none experienced a neurologic decline and all had nonfocal neurologic exams on discharge. No patient returned to the ER in delayed fashion for a neurologic decline. Of all the patient encounters, no patient required surgery.Pediatric patients ≤24 months of age presenting to the ER in delayed fashion with scalp swelling after minor head trauma-who were otherwise nonfocal on examination-did not require surgical intervention and did not experience any neurologic decline. Further radiographic investigation did not alter neurosurgical management in these patients; however, it should be noted that workup for child abuse and social care may have been influenced by CT findings, suggesting the need for the future development of a clinical decision-making tool to help safely avoid CT imaging in this setting.

Oropharyngeal trauma is common in the pediatric population. Most of these injuries are self-limited, do not require repair, and heal without complications. Because of the presence of teeth and important adjacent structures within the head and neck, some of these injuries will require acute intervention and subspecialty consultation in the emergency department. Emergency care providers must also be cognizant of injuries to the head, neck, and face as a potential hallmark for child abuse. This article reviews common oropharyngeal lesions that occur in children, including trauma, and the management of these conditions, including techniques for orofacial nerve blocks.

1. Rohit Shenoi[1][1] 2. Ned Levine[2][2] 3. Marcella Marie Donaruma-Kwoh[1][1] 4. Michelle A. Lyn[1][1] 5. Jill V. Hunter[1][1] 6. Angelo P. Giardino[1][1] 1. 1Baylor College of Medicine, Houston, TX, USA 2. 2Ned Levine and Associates, Houston, TX, USA 1. Angelo P. Giardino, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin, Suite A 2210, Houston, TX 77030, USA. Email: apgiardi{at}texaschildrens.org We evaluated the relationship between neighborhood sociodemographic factors, community resources, and homicides involving young children. We performed spatial analysis of children under age five murdered in Harris County, Texas, from 1997 to 2003. Data on county population, household, socioeconomic, and residential mobility characteristics were allocated to census block groups. Age-adjusted spatial clusters of the homicides were identified. A Markov Chain Monte Carlo negative binomial regression risk model tested the relationship of age-adjusted number of child homicides to block group characteristics and distance of victim’s residence to community resources. Child maltreatment accounted for 94% of 125 homicides. In all, 64% were concentrated in 12 age-adjusted spatial clusters involving 3% of county area. Predictors for number of homicides were a larger number of single-parent households (male and female) and lower median household income. Distance to nearest community resources was not significant. Spatial clusters of child homicides were associated with low-income neighborhoods and single-parent (male and female) households. No association between the spatial clusters of child homicides and their proximity to community resources was observed. A high percentage of child homicides were concentrated in a small area of the county, which offers the potential for targeted, cost-effective interventions. [1]: #aff-1 [2]: #aff-2

Rib fractures are considered highly suspicious for nonaccidental injury in the pediatric clinical literature; however, a rib fracture classification system has not been developed. As an aid and impetus for rib fracture research, we developed a concise schema for classifying rib fracture types and fracture location that is applicable to infants. The system defined four fracture types (sternal end, buckle, transverse, and oblique) and four regions of the rib (posterior, posterolateral, anterolateral, and anterior). It was applied to all rib fractures observed during 85 consecutive infant autopsies. Rib fractures were found in 24 (28%) of the cases. A total of 158 rib fractures were identified. The proposed schema was adequate to classify 153 (97%) of the observed fractures. The results indicate that the classification system is sufficiently robust to classify rib fractures typically observed in infants and should be used by researchers investigating infant rib fractures.

This study evaluates how well pediatric chief residents can label anatomic structures, recognize circumcision, and discern abnormal anatomy on three photographs of male pre-pubertal genitalia. Additionally, this study explored aspects of pediatric training in sexual abuse and clinical practice issues regarding routine genital examination of a male patient. We asked respondents to identify anatomic structures, recognize circumcision, and assign a Tanner stage to pre-pubertal male genitalia and to recognize an abnormal finding. 92.7% of chief residents were able to correctly identify basic structures on the photo of a circumcised pre-pubertal male. Only 22% correctly recognized the abnormal example as hypospadias. Basic recognition of anatomic structures and circumcision did not achieve 100% accuracy, while an abnormal condition was missed by the majority of respondents. These data suggest a need to address education about the male genital exam in greater detail during pediatric residency training.