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Don’t Miss Injuries That May Signal Abuse :

September 15, 2017

Editor's note: The 2017 AAP National Conference & Exhibition will take place from Sept. 16-19 in Chicago.

An estimated 1,580 children younger than 18 died of abuse and neglect in 2014. Furthermore, approximately 700,000 children are maltreated each year, according to the U.S. Department of Health and Human Services.

Some children initially may present to a pediatrician’s office or emergency department with a seemingly minor injury, and doctors may mistakenly conclude that “severity of injury equals severity of risk,” said Mary Clyde Pierce, MD, FAAP, a member of the AAP Section on Child Abuse and Neglect (SOCAN).

“This is incorrect thinking that leads directly to missed opportunities for earlier recognition of abusive injuries in young children,” Dr. Pierce said.

She and SOCAN member Jonathan Thackeray, MD, FAAP, aim to help pediatricians recognize and respond to suspected abuse during a session titled “The Infant With 'Trivial' Injuries: When to Worry and What to Do (A3109).” The session will be held from 2:00-3:30 pm Monday in McCormick Place West, W195.

Numerous factors can prevent pediatricians from suspecting or reporting abuse, said Dr. Pierce, professor of pediatrics, Northwestern University Feinberg School of Medicine and Lurie Children's Hospital of Chicago. Among them are implicit bias,

relating to the parent rather than considering the child, worrying about insulting the parent/patient, concerns over radiation exposure if getting a workup for abuse, and being wrong and causing harm to the family by reporting.

Dr. Pierce is the lead author of a recently published study of 20 fatal and near-fatal cases of physical abuse. Two-thirds of the 14 children with available medical records had prior unexplained bruising.

“That article was only 20 cases, but the stories forever changed me,” she said.

During the session, Dr. Pierce and Dr. Thackeray plan to present cases and show images to illustrate how to improve detection of injuries that may signal abuse. The presenters will review red flags for abuse, such as unexplained bruising or oral injuries in a non-ambulating infant, as well as conditions that can mimic abuse.

Dr. Thackeray described the case of a 26-day-old infant who was hospitalized for three days with what was thought to be a mouth infection. After being seen by multiple subspecialists, the child was sent home. Two weeks later, the baby returned with extensive bruising and head injury.

“The original finding presumed to be an infection was actually a frenulum tear,” said Dr. Thackeray, chief medical community health officer, Dayton Children's Hospital.

The session also will include an interactive portion where attendees will use an audience response system to indicate their answers to a variety of questions. For example, the presenters may show a series of images and ask which injury indicates the greatest risk to the child. Or attendees may be asked to indicate their willingness to evaluate infants with sentinel injuries.

“I want providers to walk away recognizing that many children who are victims of maltreatment do not experience it as a single event but rather as a recurrent cycle within the family environment,” Dr. Thackeray said. “This is important because morbidity and mortality often increase with recurrent episodes of abuse.”

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