Massachusetts — Targeted Issue
ExSTRA: Evidence-Based Screening for Siblings and Contacts of Abused Children
Sept. 1, 2010 - Aug. 31, 2012

Details

Institution
Brigham & Women's Hospital/Harvard Medical School
Principal Investigator(s)
Award Amount
$532456.00

Regions

HRSA Region

1

EMSC Region

New England

HPP Region

1

NASEMSO Region

East

Contacts

Name Roles Agency Mailing Address Office Phone Email
Daniel Lindberg, MD
  • Principal Investigator
Brigham & Women's Hospital/Harvard Medical School

Disseminations

Title Published Author Abstract Publication PMID
Predictors of Injury in Contacts of Physically Abused Children 2012 Helfer Society 0
Prevalence of Abusive Injuries in Siblings and Contacts of Abused Children 2012 Society for Academic emergency Medicine 0
Prevalence of Abusive Injuries in Siblings and Contacts of Abused Children 2012 Pediatric Academic Societies 0
Prevalence of Abusive Injuries in Siblings and Contacts of Abused Children 2012 Helfer Society 0
Yield of Skeletal Survey in Older Children with Concern for Physical Abuse 2014 Society for Academic Emergency Medicine 0
Screening for Occult Injuries Among Infants with Isolated Skull Fractures 2012 Helfer Society 0
Repeat Consultations: A New Quality Metric 2011 Helfer Society 0
Forensically Significant Retinal Hemorrhages Are Not Found in Children Without TBI 2012 Helfer Society 0
Follow-Up Skeletal Survey Utility in a Large Multi-Center Population of Children with Abuse Concerns: Worth the FUSS 2012 Helfer Society 0
Cutaneous Mimics of Physical Abuse: Present, but not Pervasive 2012 Helfer Society 0
Abusive Fractures of the Hands, Feet, Spine & Pelvis on Skeletal Survey 2012 Helfer Society 0
Yield of Skeletal Survey by Age in Children Referred to Abuse Specialists 2014 Lindberg DM, Berger RP, Reynolds MS, Alwan RM, Harper NS; Examining Siblings To Recognize Abuse Investigators OBJECTIVE:
To determine rates of skeletal survey completion and injury identification as a function of age among children who underwent subspecialty evaluation for concerns of physical abuse.
STUDY DESIGN:
This was a retrospective secondary analysis of an observational study of 2609 children <60 months of age who underwent evaluation for possible physical abuse. We measured rates of skeletal survey completion and fracture identification for children separated by age into 6-month cohorts.
RESULTS:
Among 2609 subjects, 2036 (78%) had skeletal survey and 458 (18%) had at least one new fracture identified. For all age groups up to 36 months, skeletal survey was obtained in >50% of subjects, but rates decreased to less than 35% for subjects >36 months. New fracture identification rates for skeletal survey were similar between children 24-36 months of age (10.3%, 95% CI 7.2-14.2) and children 12-24 months of age (12.0%, 95% CI 9.2-15.3) CONCLUSIONS: Skeletal surveys identify new fractures in an important fraction of children referred for subspecialty consultation with concerns of physical abuse. These data support guidelines that consider skeletal survey mandatory for all such children <24 months of age and support a low threshold to obtain skeletal survey in children as old as 36 months.
The Journal of Pediatrics 24630357
Utility of Hepatic Transaminases in Children With Concern for Abuse 2013 Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP; ExSTRA investigators OBJECTIVE:
Routine testing of hepatic transaminases, amylase, and lipase has been recommended for all children evaluated for physical abuse, but rates of screening are widely variable, even among abuse specialists, and data for amylase and lipase testing are lacking. A previous study of screening in centers that endorsed routine transaminase screening suggested that using a transaminase threshold of 80 IU/L could improve injury detection. Our objectives were to prospectively validate the test characteristics of the 80-IU/L threshold and to determine the utility of amylase and lipase to detect occult abdominal injury.
METHODS:
This was a retrospective secondary analysis of the Examining Siblings To Recognize Abuse research network, a multicenter study in children younger than 10 years old who underwent subspecialty evaluation for physical abuse. We determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing. Screening studies were compared by using basic test characteristics (sensitivity, specificity) and the area under the receiver operating characteristic curve.
RESULTS:
Abdominal injuries were identified in 82 of 2890 subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for amylase and lipase were 0.67 and 0.72, respectively.
CONCLUSIONS:
Children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury.
Pediatrics 23319537
PECARN Abdominal Injury Rule Should Exclude Potentially Abused Children 2013 Lindberg DM, Berger RP, Lane WG Annals of Emergency Medicine 23969129
The utility of follow-up skeletal surveys in child abuse 2013 Harper N, Eddleman S, and Lindberg DM OBJECTIVE:
Follow-up skeletal surveys (FUSS) are performed frequently in cases of possible physical abuse based on the evidence from small retrospective cohorts. Our objective was to determine the proportion of FUSS that identified new information in a large, multicenter population of children with concerns of physical abuse.
METHODS:
This was a prospective secondary analysis of an observational study of all children <10 years of age (120 months) who underwent evaluation for possible physical abuse by 20 US child abuse teams. This analysis included all children in whom FUSS was recommended and measured rates of FUSS completion, results of FUSS, and the change in perceived likelihood of abuse before and after FUSS.
RESULTS:
Among 2890 children enrolled in the Examining Siblings To Recognize Abuse research network, 2049 underwent skeletal survey and 796 (38.8%) had FUSS. A total of 174 (21.5%) subjects had new information identified by FUSS, including 124 (15.6%) with at least 1 new fracture and 55 (6.9%) with reassuring findings compared with the initial skeletal survey. Among cases with new fractures, the estimated likelihood of abuse increased in 41 (33%) cases, and 51 cases (41%) remained at the maximum likelihood of abuse.
CONCLUSIONS:
FUSS identified new information and affected the perceived likelihood of abuse in a substantial fraction of cases in which it was completed. These data support existing guidelines and, in addition, suggest that FUSS should be considered in cases with lower initial levels of concern for abuse.
Pediatrics 23400607
Recurrent Concerns for Child Abuse: Repeated Consultations by a Subspecialty Child Abuse Team 2014 Martindale J, Swenson A, Coffman J, Newton AW, Lindberg DM; ExSTRA Investigators Physically abused children may be repeatedly reported to child protection services and undergo multiple medical evaluations. Less is known about recurrent evaluations by hospital-based child abuse teams for possible abuse. The objectives of this study were to determine the frequency of repeated consultations by child abuse teams and to describe this cohort in terms of injury pattern, perceived likelihood of abuse, disposition plan, and factors related to repeat consultation. This was a prospectively planned, secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) research network. Subjects included children younger than 10 years of age who were referred to child abuse subspecialty teams at one of 20 U.S. academic centers. Repeat consultations occurred in 101 (3.5%; 95% CI 2.9-4.2%) of 2890 subjects. The incidence of death was 4% (95% CI 1-9%) in subjects with repeated consults and 3% (95% CI 2-3%) in subjects with single consults. Perceived likelihood of abuse from initial to repeat visit remained low in 33% of subjects, remained high in 24.2% of subjects, went from low to high in 16.5%, and high to low in 26.4% of subjects. Themes identified among the subset of patients suspected of repeated abuse include return to the same environment, failure to comply with a safety plan, and abuse in foster care. Repeated consultation by child abuse specialists occurs for a minority of children. This group of children may be at higher risk of subsequent abuse and may represent an opportunity for quality improvement. Child Abuse & Neglect 24726050
Prevalence of injuries in the siblings and household contacts of abused children 2012 Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA and Berger RP Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol
among contacts of physically abused children.
Pediatrics 22778300
Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: Perhaps "uncommon" is more common than suggested 2013 Lindberg DM, Harper NS, Laskey AL, Berger RP OBJECTIVE:
Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse.
METHODS:
This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 U.S. child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS.
RESULTS:
Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified.
CONCLUSIONS:
A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS.
Pediatric Emergency Care 23283258
Predictors of Screening and Injury in Contacts of Physically Abused Children 2015 Lindberg DM, Blood EA, Campbell KA, Laskey AL, Berger RP; Examining Siblings to Recognize Abuse Study Group OBJECTIVE:
To determine rates of screening in contacts of children evaluated for physical abuse, and the relationship of clinical characteristics to screening recommendation and completion and injury identification.
STUDY DESIGN:
This is a planned secondary analysis of a prospective study of 1918 contacts of 1196 children referred for subspecialty abuse consultation in 20 US centers. We used multivariable logistic models to determine the relationship of index child characteristics, contact child characteristics, and shared characteristics to screening and injury identification.
RESULTS:
We identified injuries or disclosures of abuse in 180 (9.4%) contacts. Recommended screening was omitted in >20% of subjects for each screening modality. At least 1 screening test was more likely to be completed in contacts of index children of non-White race or Hispanic ethnicity (OR 1.45, 95% CI 1.13-1.87), with abuse-specific injuries (OR 2.15, 95% CI 1.63-2.83), with a confession (OR 2.18, 95% CI 1.17-4.07), when the history changed (OR 1.65, 95% CI 1.05-2.61), when an occult injury was found by imaging in the index child (OR 1.84, 95% CI 1.39-2.43), and when families lacked private insurance (OR 1.63, 95% CI 1.15-2.31).
CONCLUSION:
Completion of screening recommended for contacts of potentially abused children is relatively poor, despite high risk of injury. Several clinical and demographic factors were associated with increased contact screening.
The Journal of Pediatrics 23566385
Occult Injury in Bruised Infants: A Multisite Analysis 2012 Helfer Society 0
Occult Abusive Injuries in Infants with Apparently Isolated Skull Fractures 2013 Deye KP, Berger RP, Lindberg DM; ExSTRA Investigators BACKGROUND:
There is currently no consensus about which screening studies should be undertaken to identify abusive injuries in infants with apparently isolated skull fractures. Our objective was to determine rates of screening, rates of injury identification, and rates of reporting to child protective services among infants who underwent subspecialty evaluation for abuse after presenting with an apparently isolated skull fracture.
METHODS:
This was a retrospectively planned, secondary analysis of index children enrolled in a large network of children with concerns for physical abuse. For this analysis, we included infants (<12 months) who presented with signs and symptoms attributable to a skull fracture. We determined rates of skeletal survey, dedicated ophthalmologic examination and abdominal injury screening, rates of injury identification by testing and reports to child protective services.
RESULTS:
A total of 215 infants underwent abuse consultation for apparently isolated skull fractures. Skeletal surveys were performed in 201 subjects (93.4%) and identified additional fractures in 12 (5.6%; 95% confidence interval, 2.9-9.6%). Patient age, trauma history, and fracture type (simple/complex) were not sensitive predictors of finding additional fractures on skeletal survey. Only one additional fracture was associated with clinical signs or symptoms. Dedicated ophthalmologic examination was undertaken in 100 subjects (46.5%); one child had retinal hemorrhages. Hepatic transaminases were obtained in 135 subjects (62.7%), and 5 subjects (2.3%) had abdominal computed tomography. No abdominal injuries were identified. A total of 146 subjects (67.9%) were reported to child protective services.
CONCLUSION:
Infants with apparently isolated skull fractures are an important fraction of consultations for physical abuse. Additional fractures are identified in a small subset of the skeletal surveys completed in these children.
The Journal of Trauma and Acute Care Surgery 23694887
Dedicated Retinal Examination in Children Evaluated for Physical Abuse without Radiographically Identified Traumatic Brain Injury 2013 Greiner MV1, Berger RP, Thackeray JD, Lindberg DM; Examining Siblings to Recognize Abuse (ExSTRA) Investigators OBJECTIVE:
To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging.
STUDY DESIGN:
This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI.
RESULTS:
The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification.
CONCLUSIONS:
Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination.
Journal of Pediatrics 23498157
Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises 2014 Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM; Examining Siblings To Recognize Abuse Investigators OBJECTIVE:
To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising.
STUDY DESIGN:
This was a prospectively planned secondary analysis of an observational study of children<10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants<6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders.
RESULTS:
Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse.
CONCLUSIONS:
Infants younger than 6 months of age with bruising prompting subspecialty consultation for abuse have a high risk of additional serious injuries. Routine medical evaluation for young infants with bruises and concern for physical abuse should include physical examination, skeletal survey, neuroimaging, and abdominal injury screening.
The Journal of Pediatrics 24840754
Practice Patterns of Child Abuse Pediatricians When Approaching a Child with Fractures 2012 Helfer Society 0
Non-cutaneous Mimics of Physical Abuse 2012 Helfer Society 0
Injuries in Children Reported as Witnessed Cases of Abuse and Shaking 2014 Helfer Society 0
How to Start a Multi-Center Study: A Cautionary Tale 2012 Helfer Society 0