Diagnosing medical child abuse (MCA) is one of the most daunting tasks a pediatrician faces. We rely on history to make our diagnoses, and when pediatricians are given misleading, false, or incomplete histories, it is not surprising that we can end up inadvertently causing harm to children. On the other hand, missing a rare condition that can and should be treated and accusing parents of abuse is equally harmful to the child and family. Because of these challenges, MCA is often missed, and pediatricians are reluctant to even consider the diagnosis. Fortunately, a report in Pediatrics by Vega et al (10.1542/peds.2022-058926) helps provide some guidance for institutions on how to better manage these challenging cases.
After a sentinel event of a missed case of MCA in their institution, the authors report 3 identified deficits (which are likely common in many of our hospitals):
- Inadequate recognition of MCA and how to manage it once identified.
- Insufficient collaboration and communication between outpatient medical team members regarding patients with medical complexity.
- Absence of an effective, efficient way to communicate and track cases in the electronic medical record (EMR).
To address these deficiencies, they created a multidisciplinary task force designed to review potential cases, and to set up an EMR dashboard to aid in monitoring cases of potential MCA for overutilization of services. Not only is every case evaluated by a child abuse pediatrician (CAP), each case or potential case is discussed in the task force meetings. Furthermore, the task force has provided MCA education to front line clinicians through the EMR and in-person at a variety of meetings.
Overall, I would call this a best practice approach to MCA that other hospitals should consider adopting. I foresee numerous challenges for others trying to replicate their efforts, with the most important being a shortage of CAPs across the country. Most community hospitals don’t have a CAP and some large children’s hospitals only have one. Additionally, each hospital will need to make sure every member of the multidisciplinary team is afforded the time to do the important work to meet regularly and review the cases (especially those from specialties like gastroenterology that rely on busy clinical service revenue). In an era of cost-cutting and pushing productivity, this work is clearly “unfunded”. Finally, it is hard to know whether the success of the program described was a result of the personal traits of the leaders and individuals of the institution, or if the structure can be replicated elsewhere. Many MCA programs rely on champions to advocate for their implementation and sustainability, and to do the work to evaluate MCA cases, every institution will need a team of champions such as the task force described in this important article.
