Child abuse pediatricians (CAP) play a vital role in identifying and managing cases of non-accidental trauma (NAT), yet their numbers remain alarmingly low. With fewer than 400 board-certified CAPs nationwide and only 10 applicants in the most recent fellowship match cycle, many hospitals, especially community emergency departments (ED), lack immediate access to these specialists. As a result, frontline providers often bear the responsibility of recognizing and appropriately evaluating suspected child abuse. This is made more challenging by the lack of standardized protocols and the potential for implicit bias to influence decision-making. Without clear guidelines, evaluations can be inconsistent, resulting in missed cases or unnecessary investigations that may burden families and health systems.
A recent quality improvement initiative in Hospital Pediatrics by Yaphockun et al., "Standardization of the Child Physical Abuse Evaluation in a Pediatric Emergency Department," offers a potential solution to this challenge by implementing a standardized NAT evaluation protocol in a pediatric ED (10.1542/hpeds.2024-007837). This initiative included age-based guidelines, an electronic health record (EHR) order set, targeted education, and physician-specific feedback. The goal was to improve adherence to recommended workups, including skeletal surveys and laboratory testing, for children aged 24 months or younger suspected of NAT. Over the course of the year, adherence rates significantly increased, with skeletal survey orders rising from 74% to 91% and required lab testing jumping from 13% to 71%. Importantly, these improvements were consistent across racial and ethnic groups, highlighting the protocol’s potential to minimize disparities in child abuse evaluations.
By implementing standardized child abuse assessment protocols, this initiative helps close the gap created by the CAP shortage while ensuring that vulnerable children receive thorough and fair evaluations. Integrating best practices into the EHR and providing clinicians with clear, evidence-based guidelines can promote consistency, even in hospitals lacking dedicated child abuse specialists. As noted in the article, there are recognized implicit and explicit racial and socioeconomic biases that impact child abuse reporting and evaluations. These standardized protocols can work to reduce variability in decision-making and minimize the effects of biases that have historically shaped child abuse evaluations. The widespread adoption of these protocols could lead to more consistent and equitable child abuse evaluations, ensuring that all children receive the care they need.
