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Use of Imaging in Children With Witnessed Physical Abuse

Melville, John D., MD*; Hertz, Stephanie K., DO; Steiner, R. Daryl, DO; Lindberg, Daniel M., MD§ for the ExSTRA Investigators

doi: 10.1097/PEC.0000000000001096
Original Articles

Objective Physicians are occasionally asked to evaluate children who are reported to have been victims of witnessed abuse, but who have no injuries noted on examination. The rate of injury in these patients is presently unknown. This is important because abuse allegations are brought for both altruistic and other reasons. This study compares the use of skeletal survey and neuroimaging in well-appearing and clearly injured children reported to be victims of witnessed child abuse.

Methods Retrospectively planned secondary analysis of the Examination of Siblings to Recognize Abuse cohort of children referred to a child abuse pediatrician with concerns for physical abuse. Children were selected who presented to a medical provider with a history of witnessed child abuse including shaking. Rates of radiographically evident injuries are noted among children with and without injuries noted on physical examination.

Results Among 2890 children evaluated by a child abuse pediatrician, 90 children (3.1%) presented with a history of witnessed abuse. Among these, 51 children (57%) had injuries noted on physical examination; 9 (29%) of 31 skeletal surveys and 9 (35%) of 26 neuroimaging studies revealed injuries. Of 39 children (43%) with witnessed abuse and normal examination, 3 (10%) of 30 skeletal surveys and 2 (8%) of 25 neuroimaging studies revealed an injury.

Conclusions A significant minority of children evaluated for allegations of witnessed abuse will have occult injuries identified radiographically. Absence of injury on examination should not deter physicians from obtaining otherwise indicated skeletal surveys and neuroimaging in children reported to have experienced witnessed abuse.

From the *Division of Child Abuse Pediatrics, Medical University of South Carolina, Charleston, SC;

Akron Children's Hospital,

CARE Center, Akron Children's Hospital, Akron, OH;

§Department of Emergency Medicine, Kempe Center for the Prevention and Treatment of Child Abuse, University of Colorado School of Medicine, Aurora, CO.

Disclosure: The authors J.D.M., R.D.S., and D.M.L. have provided paid expert testimony in cases of alleged child abuse. This project was supported by a grant from the Health Resources and Services Administration/Maternal and Child Health Bureau, Emergency Services for Children Program (H34MC19346-01-02). D.M.L.'s effort is funded in part by an Eleanor and Miles Shore Fellowship for Scholars in Medicine from Harvard Medical School. Funders did not participate in writing the paper or approving its publication.

Reprints: John Donald Melville, MD, Child Advocacy Center, Akron Children's Hospital, 6505 Market St, Bldg C, Suite 3100, Boardman, OH 44512 (e-mail:

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