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Oral injuries and occult harm in children evaluated for abuse
  1. Molly V Dorfman1,
  2. James B Metz2,
  3. Kenneth W Feldman2,
  4. Reid Farris3,
  5. Daniel M Lindberg4
  6. on behalf of the ExSTRA Investigators
  1. 1Pediatric Critical Care Medicine, Valley Children’s Hospital, Madera, California, USA
  2. 2Children’s Protection Program, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
  3. 3Pediatric Critical Care, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington, USA
  4. 4Department of Emergency Medicine, University of Colorado School of Medicine, Seattle, Washington, USA
  1. Correspondence to Dr Kenneth W Feldman, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA 98105, USA; kfeldman{at}u.washington.edu

Abstract

Objective To determine the frequency of occult trauma in children with oral injury evaluated for physical abuse.

Design This was a retrospectively planned secondary analysis of a prospective, observational study.

Setting Emergency departments supported by 20 US child abuse teams in the Examining Siblings to Recognize Abuse (ExSTRA) network.

Patients Children <120 months old evaluated for physical abuse.

Interventions Analysis of index children with oral injury on initial examination.

Main outcome measures Rates of physician-recognised oral injury, as well as frequency and results of occult injury testing. Perceived abuse likelihood was described on a 7-point scale (7=definite abuse).

Results Among 2890 child abuse consultations, 3.3% (n=96) of children had oral injury. Forty-two per cent were 0–12 months old, 39% 1–3 years old and 18% >3 years old. Oral injury was the primary reason for evaluation for 32 (33%). Forty-three per cent (42/96) had frenum injuries. Skeletal surveys were obtained for 84% and 25% of these identified occult fractures. Seventy-five per cent had neuroimaging; 38% identified injuries. Forty-one per cent of children with oral injuries had retinal examinations; 24% of exams showed retinal haemorrhages. More occult injuries were found in children with oral injuries than other ExSTRA subjects. A high level of concern for abusive injury was present in 67% of children with oral injury versus 33% without.

Conclusions Children with oral injury are at high risk for additional occult abusive injuries. Infants and mobile preschoolers are at risk. Young children with unexplained oral injury should be evaluated for abuse.

  • child abuse
  • general paediatrics

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Footnotes

  • Contributors The parent ExSTRA study was conceived and directed by DML. DML has access to all the original data. KWF was a contributor to the ExSTRA data set. All the authors participated in the conception and execution of this study and with the development and editing of the paper. MVD performed the data analysis under the supervision of RF as part of her Pediatric Critical Care fellowship. All authors have approved the paper as it stands.

  • Funding Dr KWF and JBM institution has received payments for legal consultation and testimony in child abuse cases.

  • Competing interests KWF and JBM’s institution has received payments for legal consultation and testimony in child abuse cases. KWF and DML have provided free child abuse legal consultation. All other authors declared no competing interests.

  • Ethics approval Data collection for ExSTRA was approved by each participating institution’s Human Subjects Review Board. This deidentified secondary analysis was determined to be exempt from Human Subjects Review by the Colorado Multi-Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data from the ExSTRA research network are available to external investigators. The ExSTRA writing and publications committee has a review process to ensure methodological validity and prevent duplicative publication. Applications for data can be made to DML (Daniel.lindberg@ucdenver.edu).

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