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OBJECTIVE: The objective of this study was to determine the level of knowledge, comfort, and training related to the medical management of child abuse among pediatrics, emergency medicine, and family medicine residents. METHODS: Surveys were administered to program directors and third-year residents at 67 residency programs. The resident survey included a 24-item quiz to assess knowledge regarding the medical management of physical and sexual child abuse. Sites were solicited from members of a network of child abuse physicians practicing at institutions with residency programs. RESULTS: Analyzable surveys were received from 53 program directors and 462 residents. Compared with emergency medicine and family medicine programs, pediatric programs were significantly larger and more likely to have a medical provider specializing in child abuse pediatrics, have faculty primarily responsible for child abuse training, use a written curriculum for child abuse training, and offer an elective rotation in child abuse. Exposure to child abuse training and abused patients was highest for pediatric residents and lowest for family medicine residents. Comfort with managing child abuse cases was lowest among family medicine residents. On the knowledge quiz, pediatric residents significantly outperformed emergency medicine and family medicine residents. Residents with high knowledge scores were significantly more likely to come from larger programs and programs that had a center, provider, or interdisciplinary team that specialized in child abuse pediatrics; had a physician on faculty responsible for child abuse training; used a written curriculum for child abuse training; and had a required rotation in child abuse pediatrics. CONCLUSIONS: By analyzing the relationship between program characteristics and residents' child abuse knowledge, we found that pediatric programs provide far more training and resources for child abuse education than emergency medicine and family medicine programs. As leaders, pediatricians must establish the importance of this topic in the pediatric education of residents of all specialties. [ABSTRACT FROM AUTHOR]

Introduction: The objective was to assess the impact of interventions associated with ongoing expert peer review on the quality of child abuse medical providers' written and photograph documentation in child sexual abuse cases., Methods: Pediatricians participated in a HIPAA compliant blind peer review process on a web platform developed to provide the American Board of Pediatrics maintenance of certification. Participants submit sequential photograph and written documentation of child sexual abuse examinations over 1 year. Documentation includes genital examination descriptions and interpretation of findings. Reviewers evaluate the photographic quality and written documentation of examination findings utilizing a numerical rating system. Each case cycle is reviewed by one of four experts in child abuse who received training in a uniform evaluation process. Reviewers follow each case throughout three cycles of documentation, selecting from several interventions that have been customized to address the quality issues noted. The third and final cycle includes summary comments from the reviewer., Results: Forty-one participants completed the program at the time these data were collected. A paired t test analysis of the combined scores of the three measures, such as Image Quality, Quality of Written Documentation, and Accuracy of Exam Interpretation, showed a statistically significant improvement ( P < 0.001) between the first and last sets. In addition, each of the individual measures was statistically significant between the first and last case sets with a P value of <0.05 for each., Conclusion: Peer review with interventions customized to address quality issues improved the quality of the assessment and documentation of child sexual abuse evaluations., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Falls are commonly reported in children who present with both accidental and inflicted brain injuries. Short falls rarely result in serious or life-threatening injuries. Our purpose is to describe a series of cases of short falls with occipital impact leading to subdural hemorrhage (SDH)., Methods: We present a series of 8 witnessed accounts of young children diagnosed as having SDHs after striking the back of their heads during a short fall. Child-abuse physicians were surveyed to determine if they had evaluated a child younger than 24 months diagnosed as having SDH, with or without retinal hemorrhages, following a witnessed fall with occipital impact. Submitted cases were analyzed., Results: The median age of the children was 12.5 months. All fell backward from a standing or seated position onto a hard surface and immediately developed symptoms. There was an average of 4 witnesses per case. Physical examinations were normal; however, the majority of children had enlarged head circumferences. All were previously healthy. Six of 8 children had unilateral convexity SDH. All children had varying degrees of retinal hemorrhage but no retinoschisis. The majority of children had returned to their baseline within 24 hours of hospitalization., Conclusions: Although a larger study is needed to identify the full spectrum of injuries, we postulate that, if a history of a fall with an occipital impact is elicited during a trauma workup, accidental injury should be considered.

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus., (Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

The objective of this study was to ascertain beliefs and knowledge of pediatricians and parents regarding the hymen and to evaluate parental and pediatrician attitudes regarding sex education by pediatricians. Surveys were distributed anonymously to parents and pediatricians. Survey questions included knowledge of the female hymen and questions regarding attitudes toward sexual health education. There was a statistically significant difference in mean knowledge scores between pediatricians and parents regarding the hymen (3.7 versus 1.3; p < 0.0001). Almost two-thirds of pediatricians (63%) felt comfortable providing sexual health education directly to their patients, but only 41% felt comfortable educating parents. Pediatricians and parents demonstrate knowledge gaps about the hymen.

Objectives: To determine how well experts agree when assessing child sexual abuse cases., Methods: A total of twelve physician subjects were recruited and voluntarily enrolled from an existing peer review network. Experts from the network had been chosen for their experience in the field and their affiliation with children's advocacy centers. Each expert submitted three cases of prepubertal female genital examinations clearly demonstrable of the case findings. Submitted cases included demographics, history, physical and genital exam findings, photodocumentation, and diagnosis. Experts reviewed each submitted case and labeled the case negative for physical finding(s), positive for physical finding(s), or indeterminate. Cases were analyzed to determine the level of agreement., Results: Thirty-six cases were submitted for use in this study; one case was excluded prior to starting the review process. After all experts completed their reviews the authors reviewed the cases and results. Two additional cases were excluded, one due to poor quality photodocumentation and one for not meeting the study criteria. Thirty-three cases were used for data analysis. All 12 expert reviewers agreed in 15 of the cases. Overall, in 22 of 33 (67%) cases at least 11 of the 12 reviewers agreed with the original diagnosis. Six of 33 (18%) cases had variable agreement (8-10 reviewers agreed with original diagnosis) among reviewers; 5 of 33 (15%) cases had poor or mixed agreement (7 or less reviewers agreed with original diagnosis)., Conclusions: Experts exhibit consensus in cases where the findings clearly are normal and abnormal, but demonstrate much more variability in cases where the diagnostic decisions are less obvious. Most of the diagnostic variability is due to interpretation of the findings as normal, abnormal or indeterminate, not on the perception of the examination findings themselves. More research should be done to develop a national consensus on the accurate interpretation of anogenital examination findings. Photographic image quality plays an important role in this quality review process and universally needs to be improved., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objectives: (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions., Methods: Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey., Results: The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008)., Conclusions: Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Sexual abuse often is the primary diagnosis considered when prepubertal girls present with vaginal trauma. Although sexual abuse is very concerning and should remain high in the differential diagnosis, a variety of accidental injuries also can cause genital injury., Case: A 5-year-old girl presented to the emergency department with genital bleeding after a vehicle rolled over her pelvis. She had isolated vaginal lacerations on exam., Summary and Conclusion: Extreme pelvic compression is an adequate mechanism of injury in a child presenting with vaginal laceration.

Objective: To determine the occurrence of bruising near the site of fracture in a group of children with inflicted fractures., Design: Case series., Setting: Two children's hospitals., Participants: Suspected child abuse victims with fractures., Main Outcome Measure: The presence of bruising and fracture in a single body region or appendage., Results: The study included 192 children with inflicted fractures. No bruising was found in 111 (57.8%) of the study participants. Forty patients (20.8%) had bruising near the site of at least 1 fracture. Of these, bruising or subgaleal hematoma near the site of a skull fracture was seen most often, in 43.3% of patients. Bruising in association with extremity fractures was seen much less commonly, ranging from 3.8% (n = 2) of children with tibia fracture to 16.7% (n = 1) of children with fibula fracture. Rib fractures also were associated uncommonly with bruising. When skull fractures are excluded, 45 (8.1%) of 555 fractures had bruising near the fracture site, in 13 (6.8%) patients., Conclusions: In children with inflicted skeletal trauma, the fractured bones that most frequently have associated bruising are the skull bones. The presence of bruising near the fracture site is uncommon in extremity or rib fractures.

Objective: Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma., Methods: All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected., Results: There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) (p=.003)., Conclusion: In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.

Background: Children who may have been sexually abused are examined in many different settings by medical providers with variable levels of education and experience in this special area of practice. Therefore, there is a need for a consistent evidence-based approach that is agreed upon by medical experts., Objectives: To develop and provide guidelines and recommendations for performing and interpreting findings of the medical evaluation of children referred for sexual abuse medical evaluations, and to provide guidelines for the education, oversight, and peer review process for clinicians who provide assessments for suspected child sexual abuse., Methods: Participation from medical providers was solicited through postings on the Internet list-serves administered by Cornell University (Special Interest Group in Child Abuse), and by the Ray E. Helfer Society, an honorary society for physician specialists in child abuse diagnosis and treatment. The guidelines were developed through review and critique of published research studies, discussions in focus group meetings at child abuse medical conferences, and ongoing communication leading to revision of draft documents., Results: Groups of 10 to 40 physician experts met at child abuse conferences between January 2002 and January 2005 to revise the table summarizing the interpretation of physical and laboratory findings in suspected child sexual abuse and to develop guidelines for medical care for sexually abused children. Between January and December 2005, the guidelines were expanded and revised., Conclusions: The guidelines presented here reflect the current knowledge, recommended clinical approaches, and required competencies in the field of child sexual abuse medical evaluation.

Purpose: To assess the training, comfort, and knowledge related to the medical management of child abuse among emergency medicine, family medicine, and pediatric residents., Method: In 2004, a 25-item survey was distributed to 274 pediatric, emergency medicine, and family medicine residents at two medical schools in Norfolk, Virginia and Dallas, Texas. Analyses focused on identifying differences in training, comfort, and knowledge by specialty and site, and identifying factors associated with greater knowledge and comfort., Results: Pediatric residents reported receiving the most hours of instruction in child abuse during residency. Training experiences of family medicine residents differed significantly by site. Clinical and overall knowledge and comfort with handling exams correlated strongly with the number of abuse patients seen during residency. On both clinical and overall knowledge, family medicine residents performed significantly worse than pediatric and emergency medicine residents. Knowledge of genital anatomy and comfort with sexual abuse exams was poor among all specialties., Conclusion: The results support the need for improvements in and a more systematic approach to residency training in child abuse.

Background: Scientific and courtroom debate exists regarding the timing of onset of symptoms and the mechanism of injury in infants and children with inflicted traumatic brain injury (ITBI)., Objectives: To determine the time interval between ITBI and the onset of symptoms and to explore the mechanism of ITBI., Design, Setting, and Patients: Retrospective review of all cases of pediatric ITBI admitted between January 1, 1981, and July 31, 2001, to a large academic medical center and cases admitted to 2 additional academic institutions between January 1, 1996, and August 31, 2000, and January 1, 2001, and July 31, 2001, comparing 81 cases of ITBI in which perpetrators admitted to abuse with 90 cases in which no abuse admission was made. The patients with perpetrator admissions to ITBI consisted of 53 boys (65%) and 28 girls (35%). Their ages ranged from 2 weeks to 52 months., Main Outcome Measures: Characteristics associated with perpetrator admissions to ITBI in children., Results: Shaking was the most common mechanism of injury among all cases with perpetrator admissions: 55 (68%) of the 81 perpetrators admitted to shaking the children. Impact was not described in 44 (54%) of the 81 cases. In cases in which only impact was described, 60% (12/20) of the children showed skull or scalp injury, compared with 12% (4/32) with skull or scalp injury in the shake only group. In 52 (91%) of 57 cases in which the time to the onset of symptoms was described, symptoms appeared immediately after the abuse. In 5 cases (9%), the timing of symptoms was less clear, but they occurred within 24 hours. None of the children were described as behaving normally after the event., Conclusions: The symptoms of inflicted head injury in children are immediate. Most perpetrators admitted to shaking without impact. These data, combined with the relative lack of skull and scalp injury, suggest that shaking alone can produce the symptoms seen in children with ITBI.

Since the identification of child abuse as a medical diagnosis, physicians have become resources to children, families, and communities to assist in diagnosing abuse, consulting with community agencies, testifying in courts of law, administering abuse prevention programs, and participating on teams to investigate and manage child abuse. Because the distribution of pediatric specialists in child abuse is limited, primary care physicians often are asked to perform these functions. Even in the face of this increasing demand, the education of physicians in the field of child abuse is very limited. Primary care residency programs can provide a good initial base to prepare physicians for forensic evaluations. This document outlines the basic elements of residency education in child abuse and neglect.

Objective: The purpose of this article is to describe pelvic fractures in two abused male infants, and to determine if the literature describes pelvic fractures in infants as suspicious for child physical abuse., Results: Two infants are described with unexplained pelvic fractures. While in one case child abuse was obvious, careful attention to the radiological evaluation and case history led to the correct diagnosis of child abuse in the second case. A search for information regarding pelvic fractures in children resulted in information limited to the radiological and surgical literature., Conclusions: Medical providers frequently encounter children with fractures suspicious for child abuse. The most common fractures seen in abused children are metaphyseal, rib, skull, and long bone fractures. This report illustrates that pelvic fractures occurring in the absence of serious, well documented accidents should be considered highly suspicious for child physical abuse.

Background: Abusive head trauma accounts for significant morbidity and mortality in infants. We compared a Southern population of victims with those in a previous study of a Western population, which found that men, particularly fathers and mothers' boyfriends, are the most common perpetrators., Methods: All cases of child abuse identified in a teaching hospital were prospectively reviewed for cases of abusive head trauma, and the perpetrators were identified., Results: Of the 76 cases of head trauma identified, 27 met the criteria for the study. The demographics of the perpetrators closely match those of the Western group. Men are the predominant perpetrators, with fathers committing 45% and boyfriends 25% of these injuries., Conclusions: Despite the differences in study design and population demographics, men are the most common perpetrators of abusive head trauma in both populations.

Physicians have been involved in the diagnosis and treatment of victims of child abuse and neglect for more than 35 years. In the past decade, a cadre of physicians has developed extensive expertise in the field. Now, physicians are requested for expert consultation by medical, investigative, and legal colleagues. As the field advances, it has become necessary to train more physicians in the field of child abuse and forensic pediatrics as well as to standardize the curricula of the existing fellowships. A joint working group of the American Academy of Pediatrics Section on Child Abuse and Neglect and the Forensic Pediatrics Physician Leadership Group convened to develop a curriculum for medical fellowships in child abuse and neglect. The authors present the model curriculum developed by this group.

Objective: Abusive head trauma is the most common cause of morbidity and mortality in physically abused infants. Effective prevention requires the identification of potential perpetrators. No study has specifically addressed the relationship of the perpetrators of abusive head trauma ("shaken baby syndrome") to their victims. The objectives of this study were to identify the abusers and their relationship to victims in these cases., Methods: We reviewed the medical charts of 151 infants who suffered abusive head trauma to determine the perpetrator of the abuse. Caretakers were classified by level of certainty: confession to the crime, legal actions taken, or strong suspicion by the staff. The relationship of abusers to victims was analyzed., Results: Male victims accounted for 60.3% of the cases. Twenty-three percent of the children died, although death rates for boys and girls did not vary significantly. Male perpetrators outnumbered females 2.2:1, with fathers, step-fathers, and mothers' boyfriends committing over 60% of the crimes. Fathers accounted for 37% of the abusers, followed by boyfriends at 20.5%. Female baby-sitters, at 17.3%, were a large, previously unrecognized group of perpetrators. Mothers were responsible for only 12.6% of our cases. All but one of the confessed abusers were with the child at the time of onset of symptoms., Conclusions: Our data suggest male caretakers are at greater risk to abuse infants. Baby-sitters are a concerning risk group, because they represent a significant proportion of abusers, and they more easily escape prosecution. In addition, no prevention efforts have been directed at baby-sitters. These statistics could help change the focus of efforts to prevent abusive head trauma.

Syphilis is a disease very much on the rise in certain populations in this country. It has reached epidemic proportions in some areas. This trend should be a concern to physicians caring for children in the United States. Rates of congenital syphilis are continuing to rise. Certainly, the poor prenatal care received by many women is inhibiting our ability to prevent congenital syphilis. All infants should have a maternal test for syphilis clearly documented before hospital discharge. In the event that maternal history of length of disease or treatment cannot be documented, the infant should be treated with a full course of antibiotics. In addition, all symptomatic infants should be treated and followed to ascertain falling antibody titers. Acquired syphilis should be suspected in any child with either a positive test for syphilis or symptomatic syphilis in whom evidence for congenital syphilis cannot be documented. Sexual abuse must be strongly suspected even in the absence of disclosure, and the case must be reported to local child protective services. Adequate treatment and follow-up must be assured. Clinicians should refamiliarize themselves with the many and varied presentations of syphilis. Many practitioners will be faced with diagnostic and treatment decisions while the infants are still in the newborn nursery. Occasionally, a child will escape diagnosis and present with symptomatic syphilis later. This disease should not be overlooked in the differential diagnoses of many seemingly simple childhood complaints.