599 - Missed opportunities to identify red flags suggestive of child physical abuse in the pediatric emergency department.

Poster Number: 599
Publication Number: 599.103

Caroline Baughn, University of Central Florida College of Medicine, Orlando, FL, United States; Linda Ren, University of Central Florida College of Medicine, Orlando, FL, United States; Andrea Rivera-Sepulveda, Nemours Children's Hospital, Orlando, FL, United States

Background: Child maltreatment affects 1 in 7 children in the US. Younger children are at higher risk, with most fatalities occurring in those under the age of 3. Early identification and intervention could stop abuse and secure safety, but there is evidence that physicians miss opportunities.

Objective: Identify the prevalence of red flags concerning for child physical abuse in pediatric emergency department (ED).

Design/Methods: Retrospective, cross-sectional study of children under the age of 2 who visited the ED of a university-affiliated, free standing pediatric hospital in 2019. Data included demographics, chief complaint, radiologic evaluation, laboratory studies, ED metrics, disposition, and presence of historical, physical and diagnostic red flags. Red flags and workup were defined based on the American Academy of Pediatrics’ guidelines on the evaluation of suspected child physical abuse. Comparisons among groups were calculated through Chi-square, Fisher’s Exact test, and odd ratio (OR), as appropriate.

Results: We identified 962 patients. Prevalence of children under the age of 2 with injuries was 8%. Median age was 19.2 months (IQR 4.8-13.2). The top chief complaints were head injury (42%), upper extremity injury (12.6%) and lower extremity injury (9.3%). The prevalence of historical, physical, and diagnostic red flags was 32.6%, 5.9%, and 5.4%, respectively. Concern for suspected abuse (3.3%), maltreatment (0.1%) or neglect (0.2%) was documented in 3.6% of cases. Patients with historical red flags were more likely to have a skeletal survey (OR 2.0, CI 1.3-3.0), CMP (OR 2.1, CI 1.4-3.2) or urinalysis (OR 2.6, CI 1.8-3.8). Physical red flags were more likely to have a skeletal survey (OR 5.3, CI 2.2-12.6) or CMP (OR 4.5, CI 1.6-12.5). Diagnostic red flags were more likely to be found by skeletal survey (OR 6.9, CI 2.8-16.7) or neuroimaging (OR 3.1, CI 1.5-6.2). Social work was consulted on 14 patients (1.5%). The department of family services was consulted on 16 (1.7%) cases.

Conclusion(s): One in 12 children under the age of 2 present to the ED with a complaint of injury. A third have historical red flags concerning of abuse. Skeletal survey was the most consistent screening study used in the presence of any red flags. Although child abuse in those less than 2 years is not as common, establishment of the true prevalence of child abuse is by adequate diagnostic workup to uncover physical abuse. A child abuse initiative to standardize identification and workup of child physical maltreatment in the ED would increase institutional opportunities for early identification and intervention.