How often do bruised pre-mobile infants subsequently sustain abuse?

Background

About half bruised pre-mobile infants have concurrent, often occult abuse. Others had legitimate accidents, birth injuries, bleeding disorders, and/or abuse without additional abuse findings or incomplete evaluations.

Washington State's recent legal and judicial changes cause fewer infants to be determined abused, and those to not be consistently protected. State law requires “Imminent danger” for protection, yet no literature documents subsequent abuse rates. Our goal was to determine how often subsequent abuse occurs.

Participants and setting

Since 2016, emergency department (ED) triage nurses screened children less than 4-years-old for high-risk bruising. Since 2018, our electric record included a pop-up for positive nurse screens, requiring physicians to confirm bruising and its evaluation.

Methods

We reviewed positive screens for less than 6-month-olds between 12/30/2018-12/30/2021. Hospital records were reviewed for initial evaluations and subsequent abuse. The County Prosecutor's Office reviewed subsequent felony referrals.

Findings

Of 100 positive nurse screens, 40 had physician confirmed bruising. Ten (25.0 %) were confirmed accidents, 3 (7.5 %) birth related, 3 (7.5 %) bleeding disorders, 20 (50.0 %) abuse, and 4 (20.0 %) unknown. Seventy-nine percent of abused and unknown infants were discharged with protection. Before 2-years-old, two (5.0 %) children (1 abused, 1 unknown) had subsequent abuse.

Conclusion

Only 0.14 % of ED infants less than 6-months-old had bruises. ED evaluations found abuse in half. Lack of Protective Services records precluded knowing how many children remained with or were returned to caretakers or had subsequent referrals. Subsequent abuse was infrequent, but clinically important for future risk.