Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review

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  • 1 Case Western Reserve University School of Medicine;
  • | 2 Departments of Neurological Surgery and
  • | 3 Surgery, University Hospitals Cleveland Medical Center;
  • | 4 and Divisions of Pediatric Surgery and
  • | 5 Pediatric Neurosurgery, UH Rainbow Babies & Children’s Hospital, Cleveland, Ohio
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OBJECTIVE

Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk.

METHODS

A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk.

RESULTS

A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup).

CONCLUSIONS

Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

ABBREVIATIONS

CPT = child protection team; DCFS = Department of Children and Family Services; ED = emergency department; ISF = isolated skull fracture; NAT = nonaccidental trauma; PICU = pediatric intensive care unit.

OBJECTIVE

Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk.

METHODS

A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk.

RESULTS

A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup).

CONCLUSIONS

Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

In Brief

Identification of infants at risk for nonaccidental trauma remains of critical importance; however, there is no standardly accepted evaluation process. Following application of a standard protocol to evaluate infants presenting with skull fractures, researchers identified a thorough evaluation of the social situation and a skeletal survey as high-yield aspects of an evaluation for possible abuse. Future assessment of this protocol as applied in the emergency department may improve identification while conserving healthcare resources.

Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States.1,2 The incidence of traumatic brain injury and fractures attributable to abuse is significant, with 21.9 cases per 100,000 children younger than 36 months, and 50 cases per 100,000 children during their 1st year of life.3 Abusive head trauma accounts for an estimated 80% of childhood maltreatment deaths, making it the leading cause of death in this population.2,4 Children in their 1st year of life are at the greatest risk of experiencing abusive head trauma and are especially susceptible to subsequent negative health outcomes such as vision problems, developmental delays, physical disabilities, and hearing loss.5 Despite the clinical implications of a failed diagnosis, studies have shown that a large number of children presenting with nonaccidental skull fractures are not identified as being victims of abuse in initial presentation.6,7 Although there are certainly patterns of injury attributable to inflicted head trauma including diffuse axonal injury and subdural hematoma, there is no clear method of identification of abusive head trauma.8 Isolated skull fractures (ISFs), which we are defining as skull fractures without intracranial findings on cranial imaging, are difficult to attribute to NAT given the frequency with which they occur in nonabusive injuries.9 Therefore, it is of utmost importance to improve identification of NAT in high-risk children through optimization of resources in order to ensure child protection and positive health outcomes for this population going forward.

Increasing evidence suggests that children with ISFs rarely require intervention warranting admission, and they can safely be discharged home with a low risk of clinical decline.10–13 Several institutions have developed consensus guidelines for safe disposition of asymptomatic children with ISFs from the emergency department (ED).14,15 Where some studies have noted that younger age more often led to hospitalization, there is a general consensus that children for whom there is a concern for NAT may require admission to ensure safe disposition.13–16

Even the most experienced pediatric trauma centers face challenges in balancing the need to identify an abused child with timely assessment and discharge of nonserious skull fractures. For example, prior to this protocol, a determination for additional workup to evaluate for NAT was based on provider concern, imaging findings, and a description of the injury. Additionally, the workup itself varied depending on the initiating team. To better serve this patient population, our institution’s trauma committee (comprising physician members from pediatric surgery, neurosurgery, pediatric intensive care, orthopedic surgery, emergency medicine, a child protection team [CPT], and anesthesiology) developed a standard protocol for evaluation of infants younger than 12 months presenting with skull fractures. The workup included evaluations by trauma surgery, neurosurgery, social work, the CPT (pediatricians with training in child abuse), ophthalmology, and a skeletal survey, and was carried out as a quality improvement initiative. In this study, we aimed to evaluate our adherence and subsequent barriers to this protocol and to identify the highest-yield components in order to tailor our evaluation with consideration to clinical yield and cost.

Methods

A retrospective chart review was conducted at our regional level I pediatric trauma center with IRB approval through University Hospitals Cleveland Medical Center and Case Western Reserve University. The Rainbow Babies & Children’s Hospital pediatric trauma database was queried for all children diagnosed with a skull fracture who presented between August 1, 2014, and July 31, 2016. These charts were reviewed for potential inclusion. All infants younger than 12 months were included in the study (Fig. 1). A total of 45 patients were included in our analysis. Subgroup evaluation was performed in patients with ISFs.

FIG. 1.
FIG. 1.

Flow diagram for selection of patients for inclusion. RCB = Rainbow Babies & Children’s Hospital. *Benign extraaxial collections were not considered a pathologic intracranial finding.

Assessed data points included age, sex, comorbidities, diagnostic imaging, location of the skull fracture, originating hospital, fracture morphology, concurrent intracranial injury, and mechanism of injury (Table 1). Our hospital standardly obtains a neurosurgery consult for all patients with radiographic evidence of injury inclusive of skull fractures, and, as such, compliance with the neurosurgical consultation was universal. To assess adherence to our protocol, we noted whether social work evaluations, pediatric surgery consultation, CPT consultation, skeletal surveys, and ophthalmology evaluations were performed and their results assessed.

TABLE 1.

Sample characteristics for all skull fracture patients and patients with ISF

VariableAll Patients (n = 45)Patients w/ ISF (n = 30)
Mean age at injury, mos (SD)5.049 (3.14)6.06 (3.13)
Female sex23 (51.11)16 (53.3)
SDH9 (20)NA
ISF30 (66.67)30 (100)
Any ICH present15 (33.33)NA
Median LOS, days [25th, 75th]1 [1, 2]1 [0.75, 2]
Stated mechanism of injury
 Fall34 (75.56)22 (73.3)
 Collision1 (2.22)1 (3.3)
 MVC1 (2.22)1 (3.3)
 Unknown10 (22.22)7 (23.3)
 Assault2 (4.44)2 (6.7)
Presenting symptoms
 Mechanism of injury12 (26.67)8 (26.7)
 Swelling25 (55.56)15 (50.0)
 Vomiting5 (11.11)3 (10.0)
 Other17 (37.78)11 (36.7)
Admission*
 Ward16 (35.56)16 (55.2)
 PICU20 (44.44)5 (17.2)
 Sent home from ED8 (17.78)8 (27.6)
Skull fracture44 (97.8)29 (96.66)
Discharge*
 Home w/ SW follow-up12 (26.66)9 (31)
 Home w/o SW follow-up26 (57.78)18 (62.1)
 Placed elsewhere6 (13.33)2 (6.9)
Diagnostic imaging obtained
 Skull x-ray2 (4.44)2 (6.7)
 CTH44 (97.78)29 (96.7)
 MRI5 (11.11)1 (3.3)
Type of fracture*
 Comminuted or depressed10 (22.23)
 Linear, nondisplaced34 (75.56)
Intracranial findings
 None28 (62.22)28 (93.3)
 Benign extraaxial collections2 (4.44)2 (6.7)
 SAH2 (4.44)NA
 SDH9 (20)NA
 EDH4 (8.89)NA
 Contusion or IPH1 (2.22)NA
NAT evaluation
 Pediatric surgery consult37 (82.22)22 (75.9)
 Ophthalmology surgery consult35 (77.78)20 (69.0)
Ophthalmology exam findings
 Negative exam32 (71.11)19 (63.33)
 No exam performed11 (24.45)11 (27.67)
 Retinal hemorrhages2 (4.44)NA
Skeletal survey results
 Negative30 (66.7)20 (66.7)
 Not performed7 (15.6)6 (20.0)
 Other fractures noted8 (17.7)4 (13.3)
Both CPT & SW consults obtained29 (64.44)15 (50)
Only CPT consult obtained2 (4.44)1 (3.33)
Only SW consult obtained6 (13.33)6 (20)
Neither CPT nor SW consult obtained8 (17.77)8 (26.7)
CPT concern for NAT
 No11 (24.44)8 (26.7)
 Not performed14 (31.11)14 (46.7)
 Yes20 (44.44)8 (26.7)
SW concern for NAT
 No14 (31.11)11 (36.7)
 Not performed10 (22.22)9 (30.0)
 Yes21 (46.67)10 (33.3)
NAT workup conclusion
 Low suspicion of NAT, no further action21 (46.67)17 (56.7)
 Suspicion of NAT, DCFS notified24 (53.33)13 (43.3)

CTH = computed tomography head; EDH = epidural hematoma; ICH = intracranial hemorrhage; IPH = intraparenchymal hematoma; LOS = length of stay; MVC = motor vehicle collision; NA = not applicable; SAH = subarachnoid hemorrhage; SDH = subdural hematoma; SW = social work. Values represent the number of patients (%) unless stated otherwise.

Data are missing for 1 patient.

All patients with intracranial hematomas were admitted to the pediatric intensive care unit (PICU) for neurological monitoring. Patients with ISFs who were admitted were candidates for ward admission unless other injuries or concerns warranted closer neurological or hemodynamic monitoring. Admission was determined based on clinical readiness for discharge and completion of this evaluation so that some patients may have been admitted for completion of this workup.

Statistical Analysis

Summary statistics are presented as mean (standard deviation) or median (25th and 75th percentiles) for continuous variables, and frequency (percent) for categorical factors. For this exploratory study, we used basic test statistics such as the t-test, the nonparametric Wilcoxon rank-sum test, the chi-square test, and the two-sided Fisher’s exact test (as appropriate) to assess differences in risk factors between patients for whom there was a suspicion of NAT (NAT for which the Department of Children and Family Services [DCFS] was notified) versus those patients for whom there was a low suspicion of NAT (no NAT) (Table 2). We also performed univariate analysis for patients with ISF (subgroup analysis) to examine if there were significant differences among factors between those patients by categorization as NAT and no NAT (Table 3).

TABLE 2.

Interrater agreement of ratings of NAT (all skull fracture patients)

CPT Concern for NATSW Concern for NAT
NoYesTotal
No9211
Yes11718
Total101929
AgreementExpected AgreementKappaSEZProb>Z
89.66%53.75%0.77630.18524.19<0.0001

Interrater agreement of ratings of NAT for patients with ISFs between the social work and the child protective team. Cohen’s kappa: ≤ 0, no agreement; 0.01–0.20, slight agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; and 0.81–1.00, almost perfect agreement.

TABLE 3.

Interrater agreement of ratings of NAT (patients with ISF)

CPT Concern for NATSW Concern for NAT
NoYesTotal
No718
Yes077
Total7815
AgreementExpected AgreementKappaSEZProb>Z
93.33%49.78%0.86730.25593.390.0004

Interrater agreement of ratings of NAT for patients with ISFs between the social work and the child protective team. Cohen’s kappa: ≤ 0, no agreement; 0.01–0.20, slight agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate agreement; 0.61–0.80, substantial agreement; and 0.81–1.00, almost perfect agreement.

The kappa statistic was used to test interrater reliability between assessments of the CPT and social work with regard to concern for NAT. We considered p values < 0.05 to be statistically significant.

All analyses were performed using R version 3.5.2 (R Project) and Stata version 15.1 (Stata Corp.).

Results

Entire Cohort

A total of 45 infants meeting inclusion criteria were identified with a mean age at presentation of 5.05 months (SD 3.14 months). Demographics and evaluation results are presented in Table 1. Just over half of the patients (51.1%) were female. The most common stated mechanism of injury was a fall (75.6%), followed by unknown (22.2%). Two patients (4.4%) were stated as having been assaulted prior to presentation. Excluding patients who were brought in because of the injury mechanism (i.e., parents brought them in because of a fall or impact to the head), the most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). Seventeen patients (37.8%) presented for a reason other than their injury mechanism, swelling, or nausea/vomiting. The entire cohort had a median hospital length of stay of 1 day. Twenty patients (44.4%) were admitted to the PICU, 16 patients (35.6%) were admitted to the floor, and 8 patients (17.78%) were sent home from the ED.

Most infants presented without traumatic intracranial findings: 28 patients (62.2%) had no intracranial findings, and 2 patients (4.4%) had benign extraaxial collections of infancy and were evaluated with the ISF population. Of the 15 patients with intracranial findings, 9 had subdural hematomas (1 with a concurrent contusion), 4 had epidural hematomas, and 2 had subarachnoid hemorrhage.

The pediatric surgery team was consulted on 37 patients (82.2%). Of the 8 patients who did not receive a pediatric surgery consult, 5 were sent home from the ED. Ophthalmology examinations were performed in 75.5% of patients. Only 2 patients experienced retinal hemorrhages; both had concomitant intracranial findings (1 with a subdural hematoma and 1 with an epidural hematoma). Thirty-eight patients (84.4%) received a skeletal survey, and 8 patients (17.7%) had additional fractures. Of note, the 2 patients in whom concurrent skull radiographs and CT scans were obtained underwent initial workup at an outside hospital where they received this imaging. Skull radiographs were not otherwise included in the skeletal survey when a head CT scan was available. CPT consultation was obtained for 31 patients, and for 20 patients (44.4%) there was a concern for the possibility of NAT. Social work evaluation was performed for 35 patients, and for 21 (46.7%) there was concern for NAT. For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Six of these 24 patients were placed in alternative living situations following discharge, and the remaining patients were discharged with outpatient county social work follow-up plans.

Patients With ISF

A subgroup analysis of 30 patients with ISFs was also carried out and the results are presented in Table 1. The mean age at presentation was 6.06 months. Similar characteristics were noted for this subgroup with regard to the most common stated mechanism of injury being fall for 22 patients (73.3%). Both of the patients with a stated mechanism of assault were in the ISF group. All 8 patients who were sent home from the ED had ISFs, 5 patients (17.2%) were admitted to the PICU, and 16 patients (55.2%) were admitted to the ward. Of the 5 patients admitted to the PICU, 4 had other injuries present on admission that warranted a higher level of care, and 1 patient was transferred directly from an outside hospital to our PICU based on the outside hospital’s level of concern.

The pediatric surgery team was consulted on 22 patients (75.9%). Ophthalmology examinations were performed in 19 patients (63.3%); no patients had retinal hemorrhages. All 11 patients who did not have an ophthalmology examination had ISFs. Twenty-four patients (80%) had a skeletal survey and 4 (13.3%) of these patients had additional fractures noted. CPT consultation was obtained for 16 patients. Only 1 of the 8 patients sent home from the ED received a CPT evaluation. The CPT had concern for NAT in 8 patients (26.7%). Social work evaluation was obtained for 21 patients, and for 10 (33.3%) of these patients there was concern for NAT. Among patients with ISFs, there was suspicion of NAT in 13 patients, accounting for 43.3% of the subgroup. Only 2 of the 13 patients were placed in alternative living situations on discharge, and the remaining patients were discharged with outpatient county social work follow-up.

Interrater Reliability of CPT and Social Work

A separate evaluation of patients who received both a CPT consult and a social work evaluation was performed to determine the interrater reliability of these services. Eight patients had neither a social work nor CPT evaluation (5 of those were patients who were discharged from the ED). Twenty-nine patients in the entire cohort and 15 patients in the ISF cohort had both CPT and social work evaluations. Interrater reliability evaluation demonstrated kappa values of 0.77 and 0.87, respectively (Tables 2 and 3).

Comparison of NAT and No-NAT Groups

Characteristics of patients for whom there was a suspicion of NAT versus those for whom there was no suspicion of NAT are displayed in Table 4 for the entire cohort and Table 5 for the patients with ISF. There were no differences between sample characteristics of patients with suspected NAT and those with no suspicion of NAT with respect to age at injury, sex, the stated mechanism of injury, or the hospital length of stay. When considering the entire cohort, there was less likely a suspicion of NAT if caregivers sought evaluation simply because of the stated mechanism of injury (the most common reason for presentation was fall from a height) (p = 0.005), but this same characteristic did not reach statistical significance for the patients with ISF. The presence of a subdural hematoma on imaging was associated with suspicion of NAT (p = 0.025), whereas the absence of intracranial findings was associated with a lower likelihood of NAT concern (p = 0.034). The presence of other fractures on skeletal survey was associated with a higher likelihood of concern for NAT (p = 0.018). In both the overall and ISF cohorts, either social work or CPT concern for NAT was associated with a higher amount of reporting to the DCFS (p < 0.001).

TABLE 4.

Comparison of sample characteristics between the NAT and no-NAT groups

VariableAll Patients (n = 45)NAT, DCFS Notified (n = 24)No ?NAT (n = 21)p Value
Mean age at injury, mos (SD)5.049 (3.14)4.70 (3.24)5.45 (3.06)0.427
Female sex23 (51.11)12 (50.0)11 (52.4)0.999
SDH9 (20)8 (33.3)1 (4.8)0.0247§
ISF30 (66.67)13 (54.2)17 (81.0)0.113
Any ICH present15 (33.33)11 (45.8)4 (19.0)0.0681
Stated mechanism of injury
 Fall34 (75.56)17 (70.8)17 (81.0)0.66
 Collision1 (2.22)1 (4.2)0 (0.0)0.999§
 MVC1 (2.22)0 (0.0)1 (4.8)0.466§
 Unknown10 (22.22)7 (29.2)3 (14.3)0.296§
 Assault2 (4.44)1 (4.2)1 (4.8)0.999§
Presenting symptoms
 Mechanism of injury12 (26.67)2 (8.3)10 (47.6)0.0056§
 Swelling25 (55.56)15 (62.5)10 (47.6)0.483
 Nausea1 (2.22)1 (4.2)0 (0.0)0.999§
 Vomiting5 (11.11)3 (12.5)2 (9.5)0.999§
 Other17 (37.78)9 (37.5)8 (38.1)0.999
Median LOS, days [25th, 75th]1 [1, 2]2.00 [1.00, 2.00]1.00 [0.00, 2.00]0.054
Admission*0.007§
 Ward16 (35.56)7 (30.4)9 (42.9)
 PICU20 (44.44)15 (65.2)5 (23.8)
 Sent home from ED8 (17.78)1 (4.3)7 (33.3)
Skull fracture44 (97.8)
Discharge*<0.001§
 Home w/ SW follow-up12 (26.66)10 (43.4)0 (0.0)
 Home w/o SW follow-up26 (57.78)7 (30.4)19 (90.5)
 Placed elsewhere6 (13.33)6 (26.1)0 (0.0)
Intracranial findings
 None28 (62.22)11 (45.8)17 (81.0)0.034
 Benign extraaxial collections2 (4.44)1 (4.2)1 (4.8)0.999§
 SAH2 (4.44)0 (0.0)2 (9.5)0.212§
 SDH9 (20)8 (33.3)1 (4.8)0.025§
 EDH4 (8.89)3 (12.5)1 (4.8)0.610§
 Contusion or IPH1 (2.22)1 (4.2)0 (0.0)0.999§
NAT evaluation
 Pediatric surgery consult37 (82.22)22 (95.7)15 (71.4)0.075
 Ophthalmology surgery consult35 (77.78)23 (100.0)12 (57.1)0.002
Ophthalmology exam findings<0.001§
 Negative exam32 (71.11)21 (91.3)11 (57.9)
 No exam performed11 (24.45)0 (0.0)8 (42.1)
 Retinal hemorrhages2 (4.44)2 (8.7)0 (0.0)
Skeletal survey results0.018§
 Negative30 (66.7)16 (66.7)14 (66.7)
 Not performed7 (15.6)1 (4.2)6 (28.6)
 Other fractures noted8 (17.7)7 (29.2)1 (4.8)
CPT concern for NAT<0.001§
 No11 (24.44)2 (8.3)9 (42.9)
 Not performed14 (31.11)3 (12.5)11 (52.4)
 Yes20 (44.44)19 (79.2)1 (4.8)
SW concern for NAT<0.001§
 No14 (31.11)2 (8.3)12 (57.1)
 Not performed10 (22.22)3 (12.5)7 (33.3)
 Yes21 (46.67)19 (79.2)2 (9.5)

Values represent the number of patients (%) unless stated otherwise. Boldface type indicates statistical significance.

Data are missing for 1 patient.

t-test.

Chi-square test.

Fisher’s exact test.

Wilcoxon rank-sum test.

TABLE 5.

Comparison of sample characteristics between NAT and no NAT among patients with ISF

VariableISF Group (n = 30)NAT, DCFS Notified (n = 13)No NAT (n = 17)p Value
Mean age at injury, mos (SD)6.06 (3.13)6.05 (3.38)6.06 (3.03)0.995
Female sex16 (53.3)7 (53.8)9 (52.9)0.999
SDHNANANANA
ISF30 (100)13 (100.0)17 (100.0)NA
Any ICH presentNANANANA
Stated mechanism of injury
 Fall22 (73.3)9 (69.2)13 (76.5)0.978
 Collision1 (3.3)1 (7.7)0 (0.0)0.433§
 MVC1 (3.3)0 (0.0)1 (5.9)0.999§
 Unknown7 (23.3)4 (30.8)3 (17.6)0.666§
 Assault2 (6.7)1 (7.7)1 (5.9)0.999§
Presenting symptoms
 Mechanism of injury8 (26.7)1 (7.7)7 (41.2)0.0924§
 Swelling15 (50.0)8 (61.5)7 (41.2)0.461
 Nausea30 (100.0)13 (100.0)17 (100.0)NA
 Vomiting3 (10.0)2 (15.4)1 (5.9)0.565§
 Other11 (36.7)4 (30.8)7 (41.2)0.838
Median LOS, days [25th, 75th]1 [0.75, 2]1 [1, 2]1 [0, 1]0.113
Admission*0.046§
 Floor16 (55.2)7 (58.3)9 (52.9)
 PICU5 (17.2)4 (33.3)1 (5.9)
 Sent home from ED8 (27.6)1 (8.3)7 (41.2)
Skull fracture29 (96.66)12 (92.3)17 (100.0)0.891
Discharge*0.002§
 Home w/ SW follow-up9 (31)7 (58.3)2 (11.8)
 Home w/o SW follow-up18 (62.1)3 (25.0)15 (88.2)
 Placed elsewhere2 (6.7)2 (16.7)0 (0.0)
Diagnostic imaging obtained
 Skull x-ray2 (6.7)1 (7.7)1 (5.9)0.999§
 CTH29 (96.7)12 (92.3)17 (100.0)0.891
 MRI1 (3.3)1 (7.7)0 (0.0)0.433§
Intracranial findings
 None28 (93.3)11 (84.6)17 (100.0)0.35
 Benign extraaxial collections2 (6.7)1 (7.7)1 (5.9)0.999§
 SAHNA
 SDHNA
 EDHNA
 Contusion or IPHNA
NAT evaluation
 Pediatric surgery consult22 (75.9)11 (91.7)11 (64.7)0.219
 Ophthalmology surgery consult20 (69.0)12 (100.0)8 (47.1)0.009
Ophthalmology exam findings0.007§
 Negative exam19 (63.33)12 (92.31)7 (41.18)
 No exam performed11 (27.67)1 (7.69)10 (58.8)
 Retinal hemorrhages0
Skeletal survey results0.033§
 Negative20 (66.7)10 (76.9)10 (58.8)
 Not performed6 (20.0)0 (0.0)6 (35.3)
 Other fractures noted4 (13.3)2 (15.4)1 (5.9)
CPT concern for NAT0.001§
 No8 (26.7)2 (15.4)6 (35.3)
 Not performed14 (46.7)3 (23.1)11 (64.7)
 Yes8 (26.7)8 (61.5)0 (0.0)
SW concern for NAT<0.001§
 No11 (36.7)1 (7.7)10 (58.8)
 Not performed9 (30.0)2 (15.4)7 (41.2)
 Yes10 (33.3)10 (76.9)0 (0.0)

Values represent the number of patients (%) unless stated otherwise.

Data are missing for 1 patient.

t-test.

Chi-square test.

Fisher’s exact test.

Wilcoxon rank-sum test.

Protocol Compliance

When analyzing compliance to our protocol, 44 patients younger than 1 year with a concurrent diagnosis of skull fracture were included. For suspicion of NAT, 37 (84%) of these patients received a pediatric surgery consult, 35 patients (80%) received an ophthalmological consult, 38 patients (86%) received a skeletal survey, 29 patients (65%) received a social work consult, and 26 patients (59%) received a physician CPT consult. Only 17 patients (39%) received the complete workup protocol. In evaluation of our protocol compliance, not every child received both a social work evaluation and a CPT consult; only 29 patients in the entire cohort received both. However, due to the overlapping role of social work and the physician CPT in the evaluation of social factors that raise concern for abuse, we found that many patients received at least one of these evaluations. When readjusted to determine how many patients received a social assessment consult from one of these teams, the percentage of patients receiving the full workup increased to 73%. It was more common for a patient to be evaluated by social work than the CPT if only one service was available.

Overall, 23 patients (52%) were referred to the DCFS for at least one concern noted on the workup that may have included suspicion of abuse. In particular, those children who were referred because of suspicion of abuse had higher compliance rates. Of the 26 patients who were suspected to have NAT, 25 (96%) received a pediatric surgery consult, 25 (96%) received an ophthalmology consult, 23 (88%) received a skeletal survey, 21 (81%) received a social work consult, and 21 (81%) received a physician CPT consult.

Identification of Children at Risk

Of the 23 patients reported to the DCFS, the most pertinent aspects of the workup that warranted referral were a social history that suggested maltreatment and abnormal skeletal survey findings. Of the patients referred to the DCFS, 13 (57%) presented with concerning social history findings, such as inconsistent parent reports, troubling family dynamics, and signs of child neglect. Eight (35%) of those patients were referred because of skeletal survey findings that raised suspicion for abuse, including healing subacute femur fractures, remote rib fractures, left tibia fractures, and a history of multiple traumatic injuries with no given explanation. Furthermore, of the 14 patients presenting with an ISF who were referred to the DCFS, every patient had either an additional social history concern or positive skeletal survey finding.

Discussion

Early identification of NAT is imperative for better outcomes from injuries associated with abuse and removal of children from ongoing risk.17 Recent literature has identified risk factors and common presentations of children presenting with NAT, improving the ability to recognize and treat these vulnerable patients.18 Numerous studies have identified age as a major risk factor, specifically children 1 year of age and younger.3,19 Those children were also shown to have polytrauma to the abdomen/pelvis and higher rates of skeletal and visceral injuries.20 Other risk factors include children who were previously hospitalized. Furthermore, children sustaining abuse are more likely to be enrolled in Medicaid or have no insurance at all, pointing to evidence that abused children are more likely to be from economically disadvantaged backgrounds.3,19

Despite the presence of established risk factors and apparent signs of NAT, there is a discrepancy within the literature regarding standardized workup in the case of skull fractures. Only a limited number of hospitals routinely use standardized protocols when evaluating abuse.21,22 Given the findings of a recent study demonstrating that skull fractures can remain radiographically visible for 2 to 18 weeks, the finding of a skull fracture on imaging does not indicate acuity of the injury.23 Given the percentage of our population who had delayed presentation or no clear known injury, and in keeping with the concerns of the authors of that study, consideration of a skull fracture as a potential finding of abuse should not be ignored.5,8,23

For this reason, the American Pediatric Surgical Association recommends the identification of suspicious injuries for abuse via a team of social workers, child protective services, law enforcement, emergency medical services, and fire responders, as well as child abuse–experienced pediatricians.24 Standardizing protocols may improve identification of abuse and potentially improve utilization of hospital and ED resources by employing the highest-yield components of NAT workup to effectively and expediently identify suspected cases. Escobar et al. proposed a screening tool to assist with protocol standardization that includes “any fracture in a non-ambulating infant” as a red flag radiographic finding warranting additional evaluation.18 The implications of such optimization include reductions in cost by limiting inpatient stays when unnecessary, improvement in ED patient flow, and the appropriate leveraging of social work or the CPT.

Based on our initial analysis, achievement of 100% compliance with our protocol was difficult. In evaluating our experience to find barriers to compliance, our highest rate of overall protocol noncompliance occurred in patients who were discharged from the ED. For patients presenting outside of a trauma team activation, the initial neurosurgical consult often prompted further workup recommendations. Of these patients discharged from the ED, 3 patients were not seen by any other services; 2 of these patients had a negative skeletal survey, and 1 patient was evaluated by pediatric surgery and social work but received no other workup. Only 1 patient discharged from the ED received the complete workup, and 1 patient received all but evaluations from the ophthalmology team and the CPT. These patients presented throughout the series and thus would not represent a pure “learning curve” of the neurosurgical or emergency medicine services in obtaining these consults. Given the retrospective nature of the review, it is unknown whether there were other factors that negated the need for additional workup (i.e., if the patient had an accident witnessed by a bystander and reported by emergency medical services). However, potential factors that may indicate poor compliance could include ED providers being unaware of the protocol, failure of the ED to initiate the protocol, or failure of the neurosurgical service to recommend the protocol. This could represent human error or the potential impact of implicit bias as there was no mechanism by which to enforce compliance with this workup. Four patients who were admitted to the hospital did not receive either social work or CPT evaluation, although we were unable to assess why these patients did not receive these based on our chart review.

Given that a significantly higher compliance rate can be achieved if patients receive at least one consult to assess the home social situation, it is important to understand the varying capabilities between CPT and social work, and further determine the interchangeability of these services at any given institution. Both entities routinely evaluate the home and social situation of patients; however, a CPT physician is further able to integrate other medical issues into the context. Our evaluation of interrater reliability demonstrates good correlation between social work services and the CPT in identifying concern for NAT. It is likely that this is largely impacted by the overlap between what the two services evaluate, including the integration of consulting service recommendations into the final assessment. Although it may represent less of an “interrater reliability” than fundamental overlap, the correlation between conclusions drawn from the two services would suggest that evaluation by one service would adequately identify any areas of concern, thus reducing the resources necessary to identify children at risk.

The finding that both social work and CPTs can comparably evaluate patients within the NAT protocol is of particular importance. Within our institution, a single CPT physician provides both inpatient consultations and outpatient clinical services, which can, at times, limit availability. To avoid disposition delays, social work teams would determine the level of concern for NAT independently if they felt confident that no further input would be needed. Additionally, other medical teams would share input on their level of concern given their respective fields of evaluation. Given that this methodology was successful at our institution, there is an opportunity to formally adopt this model within the protocol and, importantly, to extrapolate this pathway in hospitals without robust CPT physician services.

We specifically found that the thoroughness of our workup appeared to be greater in patients for whom there was a suspicion of NAT; however, this relationship is only associative in nature. Given the methodology of this study, causal inference is difficult to achieve, specifically when attempting to determine whether an increasingly thorough workup truly is more effective at identifying NAT or that suspicion among providers leads to an increasing number of consultations and diagnostic studies. This latter phenomenon undoubtedly underscores the importance of understanding both implicit and explicit provider bias and its implications on the disparate use of social work or CPT physician consultation. Ultimately, an effective and standardized protocol would mitigate the effects on potentiating disparity in care.

Overall, among factors that prompted referral to the CPT, we found the highest yield in skeletal survey findings and evaluation of the social situation. This would suggest that a comprehensive social workup and thorough skeletal survey may provide the most high-yield aspects of the NAT evaluation. This is consistent with existing literature that has demonstrated that several long bone and skeletal fracture patterns have been associated with abuse.25,26 Further evaluation and analysis of potential cost savings from streamlining our protocol will help to refine our strategy and will be the subsequent aim of our trauma committee.

Only 1 of the 23 patients flagged for concern of NAT was referred to the DCFS specifically because of a positive ophthalmology examination finding. Retinal hemorrhages have been demonstrated to be more prevalent in cases of abusive head trauma as opposed to accidental head trauma. Although there is no clear retinal sign that is unique to abusive head injuries, the presence of bilateral retinal hemorrhages is much more commonly noted in abusive head trauma, and the probability of abuse with the combination of intracranial injury and retinal hemorrhages is approximately 91%.27 Although we did not have a preponderance of patients with retinal hemorrhages, this, combined with our cohort, would suggest that ophthalmology consults would be of low yield in patients without intracranial findings.

One major limitation in our study is that we did not have a mechanism to obtain final evaluation from the county social workers who were notified of potential concerns. As many cases of abuse are only officially determined following admission or conviction, it is impossible to assess whether the notification of potential abuse ultimately resulted in action taken. Importantly, it should be noted that our protocol was adopted to standardize a workup and evaluation for children at risk of abuse. Without a clear admission from a perpetrator, our profession is unable to identify these children with 100% sensitivity or specificity. We would expect the number of children warranting a report to the DCFS would be higher than the number of children who were victims of abuse. The goal of any such protocol should be to reduce the number of children who are missed while minimizing the number of accidental injuries that are reported, which both has psychosocial implications for the caregivers and can unintentionally overwhelm the social service system. One child evaluated and referred in this study ultimately died of abusive injuries several years after our initial evaluation for an ISF, which proved to be his sentinel injury. Despite our initial concern and notification of the county services, this child serves as a grim example of the difficulty in both identifying and protecting these children despite best efforts.

Conclusions

Our study suggests the rate of concern for NAT in infants presenting with skull fractures is substantial enough to warrant a standardized safety evaluation. Our comprehensive protocol allowed for evaluation of these patients; however, achievement of 100% compliance with the protocol was difficult. In our limited cohort, evaluation by social work or a CPT, as well as a skeletal survey, identified most children for whom there was a concern for risk. Ophthalmology evaluation in the setting of ISFs likely is of low yield but should be performed in patients with intracranial hemorrhage. Our study would also support the concept that appropriate utilization of social work in the absence of a physician CPT may adequately identify patients at risk. Further studies may be aimed at improving institutional adherence and consideration of cost implications.

Acknowledgments

We thank Hasina Momotaz, MS, biostatistician in the Case Western Reserve University Department of Population and Quantitative Health Sciences, for her statistical analysis support.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Tomei, Boruah, Potter, Hills, Dingeldein. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: Tomei, Boruah, Potter, Shammassian. Critically revising the article: Tomei, Boruah. Reviewed submitted version of manuscript: Tomei, Boruah. Approved the final version of the manuscript on behalf of all authors: Tomei. Administrative/technical/material support: Tomei.

Supplemental Information

Previous Presentations

Portions of this study were presented as a poster abstract at the annual Martha L. Leopow, MD, & Irwin H. Lepow, MD, PhD, Medical Student Research Day 2019, Case Western Reserve University, Cleveland, Ohio, September 26, 2019.

References

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    Adamo MA, Drazin D, Smith C, Waldman JB. Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes. J Neurosurg Pediatr. 2009;4(5):414419.

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    Deye KP, Berger RP, Lindberg DM. ExSTRA Investigators. Occult abusive injuries in infants with apparently isolated skull fractures. J Trauma Acute Care Surg. 2013;74(6):15531558.

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    Addioui A, Saint-Vil D, Crevier L, Beaudin M. Management of skull fractures in children less than 1 year of age. J Pediatr Surg. 2016;51(7):11461150.

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    Hassan SF, Cohn SM, Admire J, et al. Natural history and clinical implications of nondepressed skull fracture in young children. J Trauma Acute Care Surg. 2014;77(1):166169.

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    Reuveni-Salzman A, Rosenthal G, Poznanski O, et al. Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF). Childs Nerv Syst. 2016;32(9):16691674.

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    Metzger RR, Smith J, Wells M, et al. Impact of newly adopted guidelines for management of children with isolated skull fracture. J Pediatr Surg. 2014;49(12):18561860.

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    Lyons TW, Stack AM, Monuteaux MC, et al. A QI initiative to reduce hospitalization for children with isolated skull fractures. Pediatrics. 2016;137(6):e20153370.

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    Deans KJ, Thackeray J, Askegard-Giesmann JR, et al. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013;75(1):161165.

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    Escobar MA Jr, Pflugeisen BM, Duralde Y, et al. Development of a systematic protocol to identify victims of non-accidental trauma. Pediatr Surg Int. 2016;32(4):377386.

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    Myhre MC, Grøgaard JB, Dyb GA, et al. Traumatic head injury in infants and toddlers. Acta Paediatr. 2007;96(8):11591163.

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    Pontarelli EM, Jensen AR, Komlofske KM, Bliss DW. Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism? Pediatr Emerg Care. 2014;30(10):677679.

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  • 21

    Crichton KG, Cooper JN, Minneci PC, et al. A national survey on the use of screening tools to detect physical child abuse. Pediatr Surg Int. 2016;32(8):815818.

  • 22

    Naik-Mathuria B, Akinkuotu A, Wesson D. Role of the surgeon in non-accidental trauma. Pediatr Surg Int. 2015;31(7):605610.

  • 23

    Harper NS, Eddleman S, Shukla K, et al. Radiologic assessment of skull fracture healing in young children. Pediatr Emerg Care. 2021;37(4):213217.

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    Escobar MA Jr, Wallenstein KG, Christison-Lagay ER, et al. Child abuse and the pediatric surgeon: a position statement from the Trauma Committee, the Board of Governors and the Membership of the American Pediatric Surgical Association. J Pediatr Surg. 2019;54(7):12771285.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Laskey AL, Stump TE, Hicks RA, Smith JL. Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures. J Pediatr. 2013;162(1):8689.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315323.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Maguire SA, Watts PO, Shaw AD, et al. Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond). 2013;27(1):2836.

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    • Export Citation

Illustration from Seaman et al. (pp 260–267). Copyright Jane Whitney. Published with permission.

  • View in gallery

    Flow diagram for selection of patients for inclusion. RCB = Rainbow Babies & Children’s Hospital. *Benign extraaxial collections were not considered a pathologic intracranial finding.

  • 1

    Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for abusive head trauma. Pediatrics. 2016;138(1):e20153756.

  • 2

    Paul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr. 2014;3(3):195207.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Leventhal JM, Martin KD, Asnes AG. Fractures and traumatic brain injuries: abuse versus accidents in a US database of hospitalized children. Pediatrics. 2010;126(1):e104e115.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4

    Adamo MA, Drazin D, Smith C, Waldman JB. Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes. J Neurosurg Pediatr. 2009;4(5):414419.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Skellern CY, Wood DO, Murphy A, Crawford M. Non-accidental fractures in infants: risk of further abuse. J Paediatr Child Health. 2000;36(6):590592.

  • 6

    Ravichandiran N, Schuh S, Bejuk M, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):6066.

  • 7

    Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621626.

  • 8

    Roach JP, Acker SN, Bensard DD, et al. Head injury pattern in children can help differentiate accidental from non-accidental trauma. Pediatr Surg Int. 2014;30(11):11031106.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Deye KP, Berger RP, Lindberg DM. ExSTRA Investigators. Occult abusive injuries in infants with apparently isolated skull fractures. J Trauma Acute Care Surg. 2013;74(6):15531558.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Addioui A, Saint-Vil D, Crevier L, Beaudin M. Management of skull fractures in children less than 1 year of age. J Pediatr Surg. 2016;51(7):11461150.

  • 11

    Bonfield CM, Naran S, Adetayo OA, et al. Pediatric skull fractures: the need for surgical intervention, characteristics, complications, and outcomes. J Neurosurg Pediatr. 2014;14(2):205211.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Hassan SF, Cohn SM, Admire J, et al. Natural history and clinical implications of nondepressed skull fracture in young children. J Trauma Acute Care Surg. 2014;77(1):166169.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Reuveni-Salzman A, Rosenthal G, Poznanski O, et al. Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF). Childs Nerv Syst. 2016;32(9):16691674.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Metzger RR, Smith J, Wells M, et al. Impact of newly adopted guidelines for management of children with isolated skull fracture. J Pediatr Surg. 2014;49(12):18561860.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Lyons TW, Stack AM, Monuteaux MC, et al. A QI initiative to reduce hospitalization for children with isolated skull fractures. Pediatrics. 2016;137(6):e20153370.

  • 16

    Bressan S, Marchetto L, Lyons TW, et al. A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med. 2018;71(6):714724.e2.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Deans KJ, Thackeray J, Askegard-Giesmann JR, et al. Mortality increases with recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care Surg. 2013;75(1):161165.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Escobar MA Jr, Pflugeisen BM, Duralde Y, et al. Development of a systematic protocol to identify victims of non-accidental trauma. Pediatr Surg Int. 2016;32(4):377386.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Myhre MC, Grøgaard JB, Dyb GA, et al. Traumatic head injury in infants and toddlers. Acta Paediatr. 2007;96(8):11591163.

  • 20

    Pontarelli EM, Jensen AR, Komlofske KM, Bliss DW. Infant head injury in falls and nonaccidental trauma: does injury pattern correlate with mechanism? Pediatr Emerg Care. 2014;30(10):677679.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Crichton KG, Cooper JN, Minneci PC, et al. A national survey on the use of screening tools to detect physical child abuse. Pediatr Surg Int. 2016;32(8):815818.

  • 22

    Naik-Mathuria B, Akinkuotu A, Wesson D. Role of the surgeon in non-accidental trauma. Pediatr Surg Int. 2015;31(7):605610.

  • 23

    Harper NS, Eddleman S, Shukla K, et al. Radiologic assessment of skull fracture healing in young children. Pediatr Emerg Care. 2021;37(4):213217.

  • 24

    Escobar MA Jr, Wallenstein KG, Christison-Lagay ER, et al. Child abuse and the pediatric surgeon: a position statement from the Trauma Committee, the Board of Governors and the Membership of the American Pediatric Surgical Association. J Pediatr Surg. 2019;54(7):12771285.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Laskey AL, Stump TE, Hicks RA, Smith JL. Yield of skeletal surveys in children ≤ 18 months of age presenting with isolated skull fractures. J Pediatr. 2013;162(1):8689.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 26

    Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315323.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Maguire SA, Watts PO, Shaw AD, et al. Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond). 2013;27(1):2836.

    • Crossref
    • Search Google Scholar
    • Export Citation

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