Missed Recognition of Potential Abuse in Young Children Presenting to the Emergency Department: A Retrospective Study

AIM: To determine the prevalence of abuse-related red flags and the frequency of subsequent evaluations among young children presenting to the emergency department (ED) with trauma-related complaints, and to quantify the association between red flags and further evaluation.

METHODS: We conducted a retrospective cohort study of children < 3 years presenting to a tertiary paediatric ED in 2019 with trauma-related chief complaints identified from structured electronic health record (EHR) data. Red flags were categorised as historical, physical, diagnostic, or caretaker/household. Two trained abstractors independently coded red flags from explicit provider documentation; discrepancies were resolved by consensus (inter-rater reliability on a 20% sample; kappa = 0.82). Outcomes were the performance of skeletal surveys, laboratory testing, and social work/child protection consultations. Logistic regression estimated the association between red flags and any subsequent evaluation, adjusting for age.

RESULTS: Among 962 eligible trauma-related visits, 317 children (33%) had ≥ 1 documented red flag. Across the cohort, 8.6% received a skeletal survey, 4.3% had laboratory testing, and 1.5% had a social work consultation. Children with any red flag were more likely to undergo further evaluation (adjusted OR [aOR] 3.7; 95% CI: 2.5-5.4). Historical red flags were associated with skeletal survey (OR 3.7, 95% CI: 1.3-11) and laboratory tests (OR 4.1, 95% CI: 1.3-13.6). Physical red flags were associated with skeletal survey (OR 6.4, 95% CI: 2.1-19.6) and laboratories (OR 5.3, 95% CI: 1.5-19). Diagnostic red flags were associated with skeletal survey (OR 7.0, 95% CI: 2.3-21.6) and neuroimaging (OR 2.4, 95% CI: 1.3-4.5).

CONCLUSION(S): One in three children under age 3 with trauma-related ED visits had documented red flags suggestive of possible abuse, yet comprehensive evaluations were infrequent. Findings support the need for nuanced, standardised approaches that prioritise high-yield flags while avoiding extensive evaluations.