Thomas J Valvano MD JD Medical Director SCAN Team Doernbecher Childrens Hospital Associate Professor of Pediatrics Oregon Health amp Science University Disclosure I have no actual or potential conflicts of interest in relation to this presentation ID: 928528
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Slide1
Screening for Child Abuse in the Emergency Department
Thomas J. Valvano, MD, JD
Medical Director, SCAN Team
Doernbecher Children’s Hospital
Associate Professor of Pediatrics
Oregon Health & Science University
Slide2Disclosure
I have no actual or potential conflicts of interest in relation to this presentation.
Slide3Incidence
Oregon, 20181487 incidents of child physical abuse (4 fatalities)
Slide4Incidence
Oregon, 20181487 incidents of child physical abuse (4 fatalities)Often unrecognized until severe injury or death occurs.
Slide5Incidence
Oregon, 20181487 incidents of child physical abuse (4 fatalities)Often unrecognized until severe injury or death occurs.Frequently present to emergency departmentsNonspecific symptomsSeemingly “minor” injuriesFalse or misleading histories
Slide6Incidence
Oregon, 20181487 incidents of child physical abuse (4 fatalities)Often unrecognized until severe injury or death occurs.Frequently present to emergency departmentsNonspecific symptomsSeemingly “minor” injuriesFalse or misleading histories
Missed diagnosis of abuse results in additional injury, death
Slide7Netherlands
Is the history consistent?
Yes
No
a
Was there unnecessary delay in seeking medical help?
Yes
a
No
Does the onset of the injury fit with the developmental level of the child?
Yes/NA
No
a
Is the behavior of the child/the carers and the interaction appropriate?
Yes
NoaAre the findings of the top-to-toe examination in accordance with the history?YesNoaAre there any other signals that make you doubt the safety of the child or other family members? *If ‘Yes’ describe the signals in the box ‘Other comments’ below.Yes*,aNoOther comments
“Escape Form”
Slide8Netherlands
Screening rate for child abuse significantly increasedSharp increase after legal requirement for screening in all EDsDetection rate of suspected abuse was higher in children who were screened than in those not screened for abuse.
Louwers EC, Korfage IJ, Affourtit, MJ, et al. Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics 2012;130:457-464.
Slide9United Kingdom
Slide10United Kingdom
Flowchart sticker placed by nurse in notes of all injured children < 6 yearsFlowchart completed by doctorConsideration of intentional injury increasedIncrease in referrals for further opinion (not statistically significant)
Benger Jr, Pearce A. Simple intervention to improve detection of child abuse in emergency departments. BMJ 2002;324:780.
Slide11Yale
Phone consultation with CAP and in-person evaluation by SW:Children < 12 months:Long bone fractureSkull fractureRib fracture
Intracranial injuryBurn
Solid organ injury (laboratory or imaging evidence)
Bruising of ear, head, neck, torso
Subconjunctival
hemorrhage
Frenulum tear
Hemotympanum
Slide12Yale
ResultsIncrease in CAP and SW consultsDecrease in racial and economic disparity in CAP and SW consults, reports to CPSIncrease in testing for nonaccidental traumaNo increase in detection of abuse (small sample size and low prevalence of abuse)
Powers E, Tiyyagura
G,
Asnes
AG, et al. Early involvement of the child protection team in the care of injured infants in a pediatric emergency department. J
Emer
Med 2019;56:592-600.
Slide13OHSU
Do not currently require mandatory SCAN consult for specific injuriesSkull fractures/intracranial injury in infants under 12 monthsBruises in nonmobile infants Fractures in children under 2 yearsNo perfect and validated screening tool
Detailed tools are lengthy and cumbersomeSimple tools are not specific enough to be useful
Slide14Sentinel Injuries
Minor abusive injuries that precede more serious abuseSentinel injuries include:Bruises in non-mobile infants Oral injuries
Subconjunctival hemorrhagesAlmost 30% of abused children had previous sentinel injury
Sheets, LK et al. Sentinel injuries in infants evaluated for child physical abuse.
Pediatrics
. 2013;131:701-707
Slide15Ten-4 Bruising Clinical Decision Rule
Children < 4 years old: Torso
Ears Neck
Anywhere on infant < 4 months old
Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising
characteristics discriminating physical child abuse from accidental trauma.
Pediatrics
. 2010;125(1):67-74.
Epub
Dec. 7, 2009.
Erratum in
Pediatrics
. 2010;125(4):861.
Slide16Red Flags
No history or changing historyHistory inconsistent with developmental abilitiesMechanism inconsistent with injury
Other signs of abuse/neglect:Bruises, scars, old fractures Failure to thrivePrior injuries
Social risk factors
IPV
Substance Abuse
Slide17ANYONE CAN ABUSE A CHILD!
Slide18Slide19Suspected Child Abuse and Neglect (SCAN) Team
Team comprised of:Physicians: Thomas Valvano, Tamara Grigsby Nurse Practitioner: Noelle Nurre, PNPSocial WorkerAvailable 24/7 in person or by telephoneSmartWeb
On Call Child AbuseInvolve the SCAN team early: 503-494-4567 or 503-494-9000 (ask for on-call
SCAN provider)