Most of the children assigned to the “normal examination” group had no documented physical examination findings other than a notation of a normal examination. A total of 3 cases with findings unrelated to abuse, diaper rash, stigmata of congenital syndrome, and a “sleepy child,” were included in the normal examination group. In the case of the sleepy child, the CAP who evaluated the 12-month-old infant documented both “no injury” on physical examination and a “normal” mental status.
Table 3 displays demographic characteristics of children who are reported to have experienced witnessed abuse, compared with the entire cohort of children referred to a CAP. Among children with witnessed abuse, those with normal examinations are significantly younger than children with clinical signs of injury (P = 0.010.)
As shown in Table 3, the yield of skeletal survey, follow-up skeletal survey, and neuroimaging among children with reported witnessed abuse, a normal examination, and completed imaging studies were 10%, 10%, and 8%, respectively. One skeletal survey and 2 neuroimaging studies were not completed that would have been indicated based on the patients' age. Compliance with follow-up skeletal survey, which requires the patient to return approximately 2 weeks after the evaluation, was only 33%. Assuming that all the studies indicated by the patient's age but not performed had been normal, the yield of skeletal survey, follow-up skeletal survey, and neuroimaging would be 8%, 3%, and 5%, respectively.
This study is aimed at a specific clinical situation, an allegation of witnessed physical abuse in a well-appearing child with a normal physical examination. This presentation, even though unusual, is not rare. On average, participating ExSTRA sites encountered this situation more than once a year.
Our data suggest that children alleged to be victims of witnessed abuse should have a radiologic workup for occult injury. Currently, we recommend skeletal survey for children aged younger than 2 years.5 Noncontrast head CT is indicated for children with multiple fractures, rib fractures, injuries to the face, or who are aged younger than 6 months.3 In this cohort, failure to complete the radiologic workup would have missed findings in 4 (10%) of 39 patients with normal examinations. One child had findings on both skeletal survey and neuroimaging.
The yield of skeletal survey in children with witnessed abuse and a normal examination (10%) is similar to the yield of other recommended imaging tests. A previous analysis of the ExSTRA data set found that 11.9% of siblings and contacts of abused children have positive skeletal surveys.14 In a recent sample of 703 consecutive skeletal surveys obtained because of concern for abuse, 10.8% showed positive results.4
This recommendation that reports of witnessed abuse prompt a radiologic workup is consistent with the actual practice of the ExSTRA investigators. Of 57 patients aged younger than 24 months, 53 patients (93%) were evaluated with a skeletal survey. Of 36 patients aged younger than 6 months, 31 patients (86%) underwent neuroimaging.
As mentioned previously, witnessed assault is frequently used as a criterion standard for the diagnosis of abuse in children with traumatic injuries. The data presented here do not suggest that reports of witnessed abuse are frequently unreliable. In our sample, 52 (57%) of 91 children with witnessed abuse had physical examination findings consistent with that history. Skeletal survey and neuroimaging identified injuries in 30% and 36% of these children, respectively. An additional of 4 children without injuries noted on examination had radiographic evidence of trauma.
The yield of skeletal survey and neuroimaging is lower in children without injuries noted on examination than those with injuries. This finding could be explained by reasoning that abuse that does not cause visible injury might be less severe than abuse that does. Thus, abuse that did not leave cutaneous injury might be less likely to cause skeletal injury as well. However, we cannot exclude the possibility that in some cases, no skeletal injury was found because the histories were fabricated or incorrect.
Strengths of this study include that it was a multicenter, study in which data was obtained prospectively, and in which regular audits ensured that all eligible children were enrolled. Weaknesses include that few children had experienced witnessed abuse with no physical examination findings.
This was a retrospective, observational study. Some information, such as the specific diagnoses on the positive imaging studies, was not uniformly recorded. Most of the patients entered the study because the CAP checked a box indicating that the event was “witnessed.” The accompanying history frequently did not delineate who witnessed or who committed the abuse. This prevents us from analyzing if some types of witnesses were more reliable than others.
This study addresses only children who were referred to the hospital's child protection team for evaluation. Anecdotally, many of the participating centers report a policy of referring all reported child abuse to the child protection team. Emergency physicians and other front-line providers, however, may have elected not to refer a child to the child protection team despite a report of witnessed child abuse if they performed all the tests, and these were negative. If this happened, it would decrease the yield of testing. These results are therefore most applicable to cases in which consultation occurs, and not to the overall population of children seen in an emergency department.
Physicians are occasionally asked to evaluate children who were reportedly the victims of witnessed abuse but who seem healthy and have a normal examination. This situation leads to concerns that false reporting may lead to excessive use of ionizing radiation for child abuse workups. The results of this multicenter observational study suggest that a minority of these children will have significant finding on skeletal survey or neuroimaging. Given the potentially dire consequences of missing child abuse, especially in this younger population, skeletal survey and head CT are indicated for children aged younger than 2 years and 6 months, respectively.
The ExSTRA investigators are: Jayme Coffman, MD (Cook Children's Hospital, Fort Worth, Tex), Deb Bretl, APNP (Children's Hospital Wisconsin, Wauwatosa, Wis), Nancy Harper, MD (Driscoll Children's Hospital, Corpus Christi, Tex), Katherine Deye, MD (Children's National Medical Center, Washington, DC), Antoinette L. Laskey, MD, and Tara Harris, MD (Riley Hospital for Children, Indianapolis, Ind), Yolanda Duralde, MD (Mary Bridge Children's Health Center, Tacoma, Wash), Marcella Donaruma-Kwoh, MD (Texas Children's Hospital, Houston, Tex), Daryl Steiner, DO (Akron Children's Hospital, Akron, Ohio), Ken Feldman, MD (Seattle Children's Hospital, Seattle, Wash), Kimberly Schwartz, MD (University of Massachusetts Medical Center, Worcester, Mass), Robert A. Shapiro, MD, and Mary Greiner, MD (Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio), Alice Newton, MD (Boston Children's Hospital, Boston, Mass), Rachel Berger, MD, MPH, and Ivone Kim, MD (Children's Hospital Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pa), Kent Hymel, MD (Dartmouth-Hitchcock Medical Center, Lebanon, NH), Suzanne Haney, MD (Children's Hospital and Medical Center, Omaha, Neb), Alicia Pekarsky, MD (SUNY Upstate Medical University, Syracuse, NY), Andrea Asnes, MD (Yale-New Haven Children's Hospital, New Haven, Conn), Paul McPherson, MD (Akron Children's Hospital, Youngstown, Ohio), Neha Mehta, MD (Sunrise Children's Hospital, Las Vegas, Nev), and Gwendolyn Gladstone, MD (Exeter Pediatric Associates, Exeter, NH).
1. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated for child physical abuse. Pediatrics
2. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA
3. Rubin DM, Christian CW, Bilaniuk LT, et al. Occult head injury in high-risk abused children. Pediatrics
4. Duffy SO, Squires J, Fromkin JB, et al. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics
5. Laskey A, Holsti M, Runyan D, et al. Occult head trauma in young suspected victims of physical abuse. J Pediatr
6. Christian CW and the Committee on Child Abuse
and Neglect. The evaluation of suspected child physical abuse. Pediatrics
7. Laskey AL, Stump TE, Hicks RA, et al. Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures. J Pediatr
8. Degraw M, Hicks RA, Lindberg D. Incidence of fractures among children with burns with concern regarding abuse. Pediatrics
9. Hicks RA, Stolfi A. Skeletal surveys in children with burns caused by child abuse
. Pediatr Emerg Care
. 2007;23:308–313. J Pediatr. 2004; 144(6):719–722.
10. Harper NS, Eddleman S, Lindberg DM, et al. The utility of follow-up skeletal surveys in child abuse
13. Hymel KP, Wilson DF, Boos SC, et al. Derivation of a clinical prediction rule for pediatric abusive head trauma. Pediatr Crit Care Med
14. Lindberg DM, Lindsell CJ, Shapiro RA. Variability in expert assessments of child physical abuse likelihood. Pediatrics
15. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child abuse
: systematic review. BMJ
16. Mathews JD, Forsythe AV, Brady Z, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ
17. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet
. 2012;380:499–505. Brenner DJ, Hall EJ. Computed tomography–an increasing source of radiation exposure. The New England journal of medicine. Nov 29 2007;357(22):2277–2284.
18. Lindberg DM, Shapiro RA, Laskey AL, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics
19. Meyer JS, Gunderman R, Coley BD, et al. ACR Appropriateness Criteria(®) on suspected physical abuse-child. J Am Coll Radiol
Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
child abuse; witnessed; shaking; skeletal survey; imaging