May 23, 2017 / 7:16 PM / 8 months ago

Abused infants may slip through the cracks in hospital systems

Infants who are victims of physical abuse take longer to get to a hospital and are less likely to receive emergency trauma care compared to children who sustain an accidental injury, researchers in the UK say.

“Victims of severe physical abuse are mostly under one year old . . . and arrive ‘by stealth’ to hospitals, often hours after injury,” lead author Dr. Ffion Davies of University Hospitals of Leicester NHS Trust told Reuters Health by email.

“This is the same the world over,” she said. “They are much less likely to arrive by ambulance, which is the mechanism by which trauma care systems in the U.S., Canada, Australia, UK and many European countries are ‘activated.’”

This means that from the start, these abused infants are unlikely to get the attention they need. “(They) arrive to non-designated trauma hospitals, have a delay in diagnosis, delay in key urgent treatments, and fare less well than those accidentally injured,” Davies said.

The study team analyzed data from the pediatric database of the UK’s national trauma registry from April 2012, when the UK created designated trauma centers, to June 2015.

Among 7,825 children, 94 percent were classified as having an accidental injury and 6 percent as cases of suspected child abuse.

On average, the children suspected of having been abused were much younger, with half under the age of 4 months, whereas half of those with accidental injuries were at least 7 years old. The abused children also tended to have more severe injuries and had nearly three times higher rates of death, at 5.7 percent versus 2.2 percent among the accidentally injured, according to the results in the Emergency Medicine Journal.

Fewer children with suspected abuse injuries arrived at the hospital via emergency services: 25.6 percent versus 44 percent by ambulance; and 0.6 percent versus 7.6 percent by helicopter.

Children with suspected abuse injuries also took longer to reach a hospital from the time of injury, with half arriving in under eight hours, compared to less than 1.5 hours for those with accidental injuries.

Similar delays in transfer to a major trauma unit were incurred. However, the combined parental and hospital delays meant that only half of children with suspected abuse injuries reached a trauma center within 21.6 hours post-injury compared with 13.8 hours for accidental injuries.

“The key recommendations are for all hospitals - not just trauma departments - to have an awareness that these victims of severe physical abuse are infants, and need to be detected as severe injury cases by frontline staff (ER doctors and nurses),” Davies said.

As soon as an abuse case is detected, she emphasized, “the trauma care system needs to be rapidly activated in order to give these children the best chance of survival.”

“The U.S. has the same issue,” noted Dr. Hnin Khine, associate director of the Division of Pediatric Emergency Medicine of Children’s Hospital at Montefiore in New York.

“We see the same pattern of presentation, in how (parents) avoid contact with pre-hospital care and the same differences between accidental and non-accidental injury,” she told Reuters Health.

“I used to work in a trauma center,” Khine said. “The trauma system is set up for networking - like admission at the pre-hospital level - and it’s amazing when you have that. The problem is, it’s directed more at older children and adults who have accidental injury.”

Khine’s facility is not a trauma center, but she does see younger patients with severe injuries, mostly due to head injuries, she said.

“They’re not usually brought in by ambulance. Parents bring them in and say the child is vomiting and doesn’t want to eat. But often at least a day has passed and they’re very vague about how it happened,” Khine said.

“The infant doesn’t get intubated right away because parents try to elude the system and misdirect us,” she said.

While the study did a good job in presenting the problem, Khine said, “they really don’t have an answer for it. We just have to take a very detailed history and have a high suspicion when the history doesn’t match what we see. I don’t know of any system that is set up to pick up these suspected child abuse cases.”

SOURCE: Emergency Medicine Journal, online April 24, 2017.

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