Hospitals Missed Screening Opportunities for Child Abuse

More than 1,500 children die from child abuse in the U.S each year, and many more are injured. Hospitals, however, may be missing opportunities to protect these young victims of abuse.

A study published in the August issue Pediatrics showed a wide variation in how hospitals screen for hidden injuries, also called “occult injuries,” in young children with a diagnosis of physical abuse. These are injuries, such as cracked ribs or brain injuries, which may not be seen immediately during a physical exam and are only discovered via screening imaging. A series of X-rays, called a skeletal survey, are recommended by American Academy of Pediatrics guidelines for children younger than 2 years with fractures suspicious for child abuse.

The study results revealed that out of 2,500 children under 2 years old with an abuse diagnosis, only half (48 percent) were evaluated for occult fractures using skeletal surveys. The data showed a wide variation in evaluation practices among the 366 U.S. hospitals included in the study. None of the infants underwent a skeletal survey at some hospitals, while all of the infants underwent a skeletal survey at other hospitals.

“We need to work to improve and standardize care for this vulnerable population,” wrote Joanne Wood, MD, MSHP, in a blog about the study that she conducted with colleagues from The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania. “Some hospitals have begun implementing clinical guidelines and other supports to aid medical providers in identifying which young injured children should undergo an evaluation for physical abuse. Research suggests that implementation of such guidelines can decrease disparities in evaluation practices and improve the detection of abuse.

A 2012 study also led by Dr. Wood revealed variation in rates of skeletal surveys performed at 40 large pediatric hospitals — 55 percent to 93 percent — but overall, 83 percent of the children received a skeletal survey. In the current study, the investigators looked at primarily non-pediatric focused hospitals. They noted that the majority of injured children receive care at these general hospitals, which are less likely to have specialized child abuse consultants than pediatric centers.

Taking into account previous research estimates of the percentage of children expected to have occult fractures revealed on skeletal surveys, Dr. Wood and her co-authors suggest that one of every seven or eight children who participated in the study sample may have had undiagnosed occult fractures.

At CHOP, Dr. Wood is a faculty member of PolicyLab, an attending physician in the division of general pediatrics, and director of research for Safe Place: Center for Child Protection and Health. She also is an assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. The study team included Benjamin French, PhD, of biostatistics and epidemiology at Upenn; Lihai Song of healthcare analytics for PolicyLab; and Chris Feudtner, MD, MPH, PhD, an attending physician in CHOP’s division of general pediatrics and director of CHOP’s department of medical ethics.