OBJECTIVE:The reported prevalence of intracranial injuries (ICI) in asymptomatic infants undergoing physical abuse evaluations varies widely. To inform neuroimaging decisions, we sought to 1) describe ICI prevalence among asymptomatic infants evaluated for abuse, 2) assess the impact of different definitions of "asymptomatic" on ICI prevalence across different age groups, and 3) assess whether hospital-level neuroimaging rates impact prevalence of identified ICI. METHODS:We conducted a cross-sectional study of infants <12 months without seizures or altered mental status (AMS) undergoing subspecialty evaluations for physical abuse from February 2021 through December 2022 within CAPNET, a multicenter child abuse research network. We report ICI prevalence among infants without seizures or AMS and across 3 subpopulations with progressively stricter definitions of "asymptomatic." RESULTS:Of 1947 infants without seizures or AMS, 1513 (77.7%) underwent neuroimaging. Of these infants, 13.7% had ICI. After excluding infants with signs of blunt head injury, ICI prevalence decreased to 5.4%. After additionally excluding infants with neurologic signs or symptoms, ICI prevalence was 5.0%. With additional exclusion of infants with nonspecific symptoms, ICI prevalence was 4.7%. CONCLUSIONS:ICI prevalence in asymptomatic infants depends upon the definition of "asymptomatic". When strictly defined, asymptomatic ICI occurs in approximately 1 in 21 infants undergoing evaluations for abuse. Among infants without signs of blunt head trauma, infants <6 months have a higher risk of ICI compared to older infants.

OBJECTIVE:Prior research on confessions of physical abuse (PA) has explored mechanisms of injury. Little is known about conditions supporting a confession of abuse or how confessions may influence case outcomes. METHODS:This cross-sectional study of suspected PA in children aged <10 years at 10 centers participating in CAPNET, a multicenter child PA research network, included children with in-person Child Abuse Pediatrics (CAP) consultations between February 2021 and December 2022 and excluded children without injury. Our focus was a confession of inflicted injury known to the CAP during clinical involvement. We compared child and clinical characteristics, out-of-home (OOH) placements, and arrests between cases with and without confessions. Multivariable models using generalized estimating equations (GEE) produced adjusted predicted probabilities (APP) clustering by CAPNET site. RESULTS:Confessions were known to CAPs in 115/4297 (2.7%) cases, with significant site variability. In a multivariable GEE model, confessions were more likely in cases with injuries with high specificity for abuse (APP 6.0% vs 1.6%, P < .001), near-fatality (APP 5.6% vs 2.3%, P < .001), and older children (APP 4.8% vs 2.5%, P = .025). OOH placements and arrests were more common in cases with confessions. CAP awareness of confessions, OOH placements, and arrests did not follow racial or ethnic patterns seen in the US child welfare system. Lower socioeconomic status was associated with OOH placements and arrests but not with CAP awareness of confessions. CONCLUSIONS:Our findings highlight differences in case characteristics and outcomes where a confession is known to the CAP and raise questions about agency response based on child characteristics.

Abusive head trauma (AHT) is a medical diagnosis that encompasses data from clinical and experimental studies. The neuroimaging evaluation is a critical piece of the diagnosis, but should not be considered separate from the biomechanical research, clinical history, laboratory testing, and any other investigative information that is felt to be clinically warranted. Furthermore, many clinical subspecialties in addition to pediatrics and medical imaging offer supportive diagnostic information that must be incorporated in the overall analysis of a case. The ophthalmologist, critical care specialist, emergency medicine physician, trauma surgeon, and neurosurgeon play vital roles in the clinical assessment. Investigative collaboration requires a close relationship with biomechanical engineering, law enforcement, Child Protective Services (CPS), and forensic pathology. Child abuse is unique compared with other diagnostic processes because there is no single or combined set of clinical indicators that proves a child has been abused. In fact, there are many medical conditions that can mimic some or all of the indicators seen in child abuse. Laboratory testing and clinical evaluation is essential in the identification of confounding medical conditions. However, in the context of a traumatic brain injury (TBI) in an infant or young child who, in the absence of other medical factors, does not have a sufficient history of trauma to account for the injuries, AHT leads the differential diagnosis.

BACKGROUND:Siblings and household contacts of physically abused children are at increased risk for physical abuse and may have injuries that are not clinically apparent. However, injury testing recommendations for contact children remain debated. OBJECTIVE:Our objective was to describe testing practices and yield for contacts of physically abused children. PARTICIPANTS AND SETTINGS:This is a cross-sectional study of children <10 years old evaluated for physical abuse at 10 US pediatric referral centers in the CAPNET research network. METHODS:We report the proportion of contact children who had a skeletal survey (SS) or neuroimaging and describe the proportion of tests that identified injuries. RESULTS:Among 6256 index evaluations, 4863 contacts were identified. Among 794 contacts with physical examinations, 530 had no findings on physical examination and 694 had no history of trauma. Among 316 contacts <24 months old where the index child had high concern for abuse, 196 (62%) had a SS and 20 had fractures identified by the SS. SS completion was more common for twins, contacts <12 months old, and contacts with findings on physical exam. Among 123 contacts <12 months old where there was high concern for abuse in the index child, 49 (40%) had neuroimaging. Of these, 5 had intracranial hemorrhage; all were twins. CONCLUSIONS:When skeletal survey and neuroimaging were completed in contacts of abused children, injuries were more common in twins and younger contacts.

BACKGROUND AND OBJECTIVES:Intimate partner violence (IPV) and child physical abuse often co-occur, but the frequency and risk factors for abusive injuries in IPV-exposed children remain unknown. Our objectives were to (1) determine frequency of skeletal surveys (SSs) and neuroimaging use because of IPV and their diagnostic value in children aged less than 24 months evaluated by a child abuse pediatrics specialist (CAP) and (2) identify factors associated with performance of and findings on SS and neuroimaging. METHODS:We conducted a retrospective study of children aged less than 24 months undergoing CAP consultations because of IPV exposure from February 2021 to February 2024 in a multicenter child abuse research network. We analyzed use of SS and neuroimaging and associations between imaging use and sociodemographic factors and associations between imaging positivity and clinical factors (age, injury-related chief complaint, presenting trauma history, injury on physical examination). RESULTS:Among 326 children, 305 (93.6%) underwent SSs, with 29 (9.5%) positive for a new fracture. Among 267 children without signs/symptoms of head trauma, 110 (41.2%) had neuroimaging, with 7 (6.4%) positive for intracranial injury. There was no disproportionality in SS use, but race/ethnicity and insurance type were associated with the use of neuroimaging. The presence of an injury on physical examination finding was associated with newly identified fractures (15.7% vs 6.4%; P = .009). CONCLUSIONS:Current evidence supports use of SSs in children aged less than 24 months undergoing medical evaluations after exposure to IPV. Further research is needed to assess risk factors for positive findings on SSs and neuroimaging with larger sample sizes.

OBJECTIVES:Using a multicenter child abuse pediatrics research network (CAPNET), the study objectives were to characterize the adherence to American Academy of Pediatrics (AAP) recommendations for bleeding disorder testing and the frequency of bleeding disorder identification. METHODS:We performed a descriptive study of bleeding disorder evaluations among children younger than 10 years of age who presented with bruising and/or intracranial hemorrhage (ICH) concerning for abuse from February 2021-May 2022 utilizing CAPNET. Cases were classified as bruising without ICH or ICH with or without bruising. Based on AAP guidance, testing was not recommended in cases with concomitant suspicious injuries, inflicted injury history, patterned injury, and low clinical concern for abuse. The primary outcome was adherence to AAP recommendations for testing by study group. We also calculated the frequency of bleeding disorder identification. RESULTS:A total of 2491 children presented with bruising and/or ICH concerning for abuse during the study period. 25.1 % of subjects (468 with bruising and 157 with ICH) were recommended to have testing by AAP criteria. Of these, 10.5 % cases of bruising and 33.1 % cases of ICH completed all AAP recommended testing. Among CAPNET centers, AAP recommended testing completion ranged from 0 to 34.1 % of bruising cases and 4.8-100 % of ICH cases. In total, 0.7 % (18/2491) cases had a newly identified bleeding disorder, with more identified at one center with higher testing rates. CONCLUSIONS:Testing for bleeding disorders based on AAP recommendations frequently did not occur and varied by CAPNET center. Although rare, bleeding disorders were present among cases with testing.

BACKGROUND:The association between child abuse pediatric (CAP) assessments and child welfare outcomes is unknown. OBJECTIVE:To determine the association between a CAP determination of the likelihood of physical abuse and change in child placement. We hypothesized that child race would be associated with CAP determination of abuse likelihood and child welfare outcomes. PARTICIPANTS AND SETTING:Children under age ten years with in-person CAP consultation and referral to child protective services for suspected physical abuse at a U.S. pediatric referral center participating in CAPNET, a CAP research network, from 02/2021 to 01/2023. METHODS:We created a series of generalized estimating equations clustered by site, adding covariate blocks representing child characteristics, clinical case factors, and social risk indicators to understand the probability of placement change after CAP consultation. RESULTS:Of 3732 eligible children, 950 (25.5 %) experienced a placement change around a CAP consultation for physical abuse. Adjusting for site, placement change was 28.7 % (25.7-31.8 %) more likely for children with a CAP determination of a high v. lower likelihood of abuse and 6.7 % (3.1-10.4 %) more likely for children of Black/Indigenous v. other race (p < 0.001). These differences persisted with attenuation in fully adjusted models. There was no significant association between CAP determination and child race. CONCLUSIONS:CAP assessment of physical abuse likelihood is strongly associated with the probability of change in child placement. While not associated with CAP assessment of abuse likelihood, Black or Indigenous race is associated with increased probability of placement change even after adjusting for child, case, and social risk factors.

OBJECTIVES:1) To quantify hospital-level variation in use of neuroimaging to screen for intracranial injury (ICI) among infants without overt signs or symptoms of head trauma undergoing subspecialty evaluations for physical abuse; 2) to assess for disproportionality in neuroimaging based on race and ethnicity and insurance type. METHODS:This was a cross-sectional study of infants age <12 months receiving subspecialty child abuse evaluations from February 2021 to December 2022 at 10 sites in CAPNET, a multicenter child abuse research network. Infants were included if they underwent a skeletal survey and lacked overt signs of possible ICI or blunt head injury. Outcome was completion of neuroimaging (computed tomography [CT] or magnetic resonance imaging [MRI]). Multivariable logistic regression was used to assess associations between demographic, clinical, and hospital factors with neuroimaging use. RESULTS:Of 1114 infants, 746 (67%) underwent neuroimaging ranging from 51% to 80% across CAPNET hospitals. In multivariable analysis, young age, presence of rib fracture(s), and site had significant associations with neuroimaging. Insurance type and race and ethnicity did not contribute significantly to the model. After adjustment for case-mix, there was significant variation across hospitals, with neuroimaging use ranging from 51% (95% CI: 43%, 59%) to 79% (95% CI 71%, 88%). CONCLUSION:We identified significant variation in neuroimaging use across CAPNET hospitals, highlighting the need for guideline development and care standardization during the care of infants undergoing abuse evaluations.

BACKGROUND:Skeletal surveys (SS) are recommended for the evaluation of suspected physical abuse in children <2 years old. No guidelines exist for SS completion in children between 2 and 5 years old. OBJECTIVE:To determine rates of SS completion by age and examine variables associated with occult fracture identification in older children. PARTICIPANTS AND SETTING:Observational cross-sectional multi-center study of 10 US pediatric centers 2/2021-9/2022 including children <6 years old evaluated for physical child abuse. METHODS:The principal outcome is occult fracture identified on SS. Non-parametric tests were conducted from comparison between age groups and those with and without occult fractures. RESULTS:The rate of SS completion declined with increasing age from a high of 91 % in infants <6 months old to 7 % in children 5-5.9 years old. The proportion of SS with occult fractures also decreased with age. Of 450 children 2-5 years old with a SS, 20 [4 % (95 % CI: 3-8 %)] had an occult fracture. The rate of occult fractures among children 2-5 years old who were diagnosed with abuse and not admitted to the hospital was 0.3 % (95 % CI 0-0.6 %)]. Over 30 % of children 2-5 years old were diagnosed with child abuse by a child abuse pediatrician without completion of a SS. CONCLUSION:In children 2-5 years of age being evaluated for physical abuse, use of SS and the rate of occult fractures is low. The number of SS performed in children in this age group could potentially be decreased by up to 60 % by limiting SS to children admitted to the hospital.

OBJECTIVES:Establish the longitudinal cross-lagged associations between maltreatment exposure and child behavior problems to promote screening and the type and timing of interventions needed. METHODS:The Longitudinal Studies of Child Abuse and Neglect, a multiwave prospective cohort study of maltreatment exposure, enrolled children and caregivers (N = 1354) at approximately age 4 and followed them throughout childhood and adolescence. Families completed 7 waves of data collection with each wave occurring 2 years apart. Maltreatment was confirmed using official case records obtained from Child Protective Services. Six-month frequencies of behavior problems were assessed via caregiver-report. Two random-intercept, cross-lagged panel models tested the directional relations between maltreatment exposure and externalizing and internalizing behaviors. RESULTS:Maltreatment exposure predicted increases in externalizing behaviors at ages 8 (b = 1.06; 95% confidence interval [CI] 0.14-1.98), 12 (b = 1.09; 95% CI 0.08-2.09), and 16 (b = 1.67; 95% CI 0.30-3.05) as well as internalizing behaviors at ages 6 (b = 0.66; 95% CI 0.03-1.29), 12 (b = 1.25; 95% CI 0.33-2.17), and 14 (b = 1.92; 95% CI 0.76-2.91). Increases in externalizing behaviors predicted maltreatment exposure at age 12 (odds ratio 1.02; 95% CI 1.00-1.05). CONCLUSIONS:Maltreatment exposure is robustly associated with subsequent child behavior problems, strengthening inferences about the directionality of these relations. Early screening of externalizing behaviors in pediatric settings can identify children likely to benefit from intervention to reduce such behaviors as well as prevent maltreatment exposure at entry to adolescence.

OBJECTIVE: Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (pre-consultation referral). METHODS: Children < 5 years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with pre-consultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS: Among the 61% (1005/1657) of cases with pre-consultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Pre-consultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, pre-consultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in pre-consultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in pre-consultation referral based on race or ethnicity. CONCLUSIONS: Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.

An auricular hematoma is a collection of blood between the auricular cartilage and perichondrium layer of the external ear. It is commonly the result of direct blunt trauma, usually on the anterior aspect of the external ear with associated findings of fluctuant swelling, tenderness, and discoloration.1 Auricular hematomas are more commonly found in athletes who participate in contact sports, such as wrestling, rugby, and boxing. They have been reportedly considered to be spontaneous in extremely rare cases.2 In contrast to mobile athletes participating in extreme contact sports, infants are nonmobile. Auricular hematomas are rare in infants who are not mobile. When auricular hematomas are found in infants or children, non-accidental trauma should be part of the differential diagnoses.3-5 We report an auricular hematoma in a 4-week-old female who was also found to have classic metaphyseal fractures of the right distal and proximal tibia. Classic metaphyseal fractures are considered highly specific injuries associated with non-accidental trauma. In an infant with no history of trauma, or a history of trivial trauma, an auricular hematoma should be considered to be a sentinel injury and a non-accidental trauma workup should be performed. A sentinel injury is a relatively minor, suspicious injury, such as a bruise or frenulum tear in pre-cruising infants which may be the first indication of child physical abuse. Auricular hematomas have been rarely reported in clinical settings as resulting from abuse. One case report describes a 5-week-old female with bilateral auricular hematomas involving the superior one half of each external ear. A non-accidental trauma workup was not reported.3 Typically, the evaluation of non-accidental trauma should include a computed tomography (CT) scan, occult abdominal trauma screening bloodwork, and coagulation tests, in addition to a skeletal survey. An additional case report describes a 5-weekold male with a history of a hematoma of the left ear pinna which presented 4 hours prior to presentation. It was not stated whether non-accidental trauma workups were obtained for either cases but that the authors were unable to demonstrate co-existence of non-accidental injury and deemed the finding to be a spontaneous hematoma.1,2 To date, there have been no reported cases of auricular hematomas associated with other abusive injuries. We present a unique case of an abusive auricular hematoma in a 4-week-old female who was found to also have unilateral classic metaphyseal fractures of the right distal and proximal tibia.

This commentary is on the invited review by Squier on pages 290–297 of this issue.

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.

Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in "grab mark" contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.

BACKGROUND AND OBJECTIVE:While a changing history is frequently cited as a red flag for child abuse, no data support which changes are significant, nor the degree to which concern should be increased. We sought to measure the impact of changing caregiver histories on expert assessments of abuse likelihood.METHODS:We used a vignette survey to measure the impact of a changing history on child abuse expert assessments of abuse likelihood and willingness to undertake testing and protective interventions. By randomly varying the presence and magnitude of history changes, we determined their impact on perceived abuse likelihood.RESULTS:Of 494 invited participants, 267 (54 %) completed the survey. The presence of historical changes significantly affected experts' level of concern for abuse and willingness to test or report abuse, though to variable degrees. For example, while a minor change in the timing of an injury did not significantly increase willingness to perform a skeletal survey (OR: 1.5, 95 % CI: 0.8-2.9), a major change in the timing of an injury did (OR: 2.0, 95 % CI: 1.1-3.6). In addition, a change from having no initial history of trauma to then giving a history of accidental trauma significantly lowered the mean estimate of abuse likelihood and triggered significantly less reports to child protective services (OR: 0.02, 95 % CI: 0.003-0.2).CONCLUSION:For abuse experts, some history changes are more concerning than others, with major changes in history, and an initial denial of trauma having the largest impact. Future research regarding changing histories should consider details of the change, rather than treating all changes equally.

New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.

BACKGROUND:Retinal hemorrhages are one of the most important supportive evidences for abusive head trauma (AHT). Susceptibility-weighted imaging (SWI) is highly suited to identify various forms of intracranial hemorrhage in AHT. However its utility in imaging retinal hemorrhage is not well established.OBJECTIVE:SWI is a sensitive sequence for identifying retinal hemorrhage on MRI.MATERIALS AND METHODS:In this retrospective analysis, 26 consecutive infants and young children with a suspected admission diagnosis of AHT underwent indirect ophthalmoscopy and brain MRI protocol for AHT along with SWI. Brain susceptibility-weighted images of 14 age-matched children were used as controls. For detecting retinal hemorrhage, susceptibility-weighted images of patients and controls were reviewed randomly and independently by two neuroradiologists who were blinded to the history and ophthalmology findings. A pediatric ophthalmologist graded the indirect ophthalmoscopy images.RESULTS:A diagnosis of AHT was confirmed in all 26 cases from a multidisciplinary meeting. Indirect ophthalmoscopy images were available in 21 cases. Ophthalmoscopy was positive for retinal hemorrhage in the right eye in 18 cases (85.7%) and in the left eye in 16 cases (76.2%). On SWI, retinal hemorrhage was identified in the right eye in 9/21 cases (42.8%) and in the left eye in 8/21 cases (38.1%) of AHT. Analysis of SWI in 21 cases of AHT demonstrated a sensitivity of 50%, specificity of 100%, positive predictive value of 100% and negative predictive value of 32% for detecting retinal hemorrhage.CONCLUSION:SWI is moderately sensitive and highly specific for identifying retinal hemorrhage in AHT. Further studies are needed to identify steps to improve the efficiency of SWI in detecting retinal hemorrhage.