Each year, over 1,500 children die from child abuse and neglect in the U.S., and many more sustain non-fatal injuries. Diagnosing physical child abuse in an accurate and timely manner is crucial to protecting children and decreasing morbidity and mortality. Recognizing which young injured children may be victims of physical abuse and in need of further evaluation and protection can be challenging for medical providers. Numerous research studies have demonstrated that medical providers sometimes fail to recognize and diagnose abuse, placing children at on-going risk of harm. Variation in rates of performing evaluations for suspected physical abuse based on patient socio-demographic characteristics, provider characteristics, and site of care has been observed and raises concerns regarding the equity and quality of care provided to this vulnerable population.

In a recent study published in Pediatrics, we found tremendous variation across hospitals in rates of performance of skeletal surveys among infants with severe injuries associated with a high likelihood of abuse. The skeletal survey, a series of x-rays used to identify fractures, is a key tool in the evaluation of suspected physical abuse. The variation was extreme: at some of the hospitals, none of the infants underwent a skeletal survey, while at other hospitals, all of the infants underwent a skeletal survey. We had previously examined rates of skeletal survey performance at large pediatric hospitals and had seen some variation, but not to the degree that we observed in this study of primarily non-pediatric focused hospitals. The data revealed that, in general, hospitals with more experience caring for young injured children were more likely to obtain skeletal surveys than hospitals with less experience. The very low rates of skeletal survey performance observed at some hospitals raise concern that opportunities to diagnose abuse and protect children are being missed.

We need to work to improve and standardize care for this vulnerable population. Some hospitals have begun implementing clinical guidelines and other supports to aid medical providers in identifying which young injured children should undergo an evaluation for physical abuse. Research suggests that the implementation of such guidelines can decrease disparities in evaluation practices and improve the detection of abuse. Greater dissemination, implementation, and evaluation of clinical guidelines is needed, especially at non-pediatric focused hospitals where we may be missing opportunities to protect some of our most vulnerable children.