Bias in the workup for non-accidental trauma (NAT) in patients under age 1 brought to the emergency department for a reported fall that may be suspect for child abuse Open Access

Voss, Ava (Spring 2020)

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BACKGROUND: Non-Accidental Trauma (NAT), or child abuse, is critical to recognize in a clinical setting due to the potential for long-term sequelae, but screening for NAT has the potential for racial bias. The primary mode of screening for NAT in children less than 1 year of age is with skeletal survey, which is used to detect occult fractures. 

OBJECTIVE: The purpose of this study is to evaluate discrepancies in the workup for NAT in patients under age 1 brought to the emergency department for a reported fall that may be suspect for child abuse.

METHODS: Using the National Trauma Data Bank (NTDB) for years 2010 through 2014, participants were included if they were less than one year old and had admitting ICD-9-CM codes of “fall.” With demographic data, patients were categorized into six race categories (Table 1). Data were further dichotomized based on having received a skeletal survey. Additional variables included socioeconomic status via primary payment method, location where the incident occurred, Injury Severity Score (ISS), Traumatic Brain Injury (TBI), and two separate hospital type variables. Overall odds ratios (OR) for skeletal survey were calculated, and confidence intervals and p-values were calculated based on the chi-square and Fisher’s exact tests. Multivariable linear regression was performed using all the variables in Table 3. 

RESULTS: There were 38,948 children primarily identified with this method, of which 10.4% received a skeletal survey. The crude OR comparing odds of receiving a skeletal survey among non-white children compared to black or African American children was 1.56 [1.43, 1.69] with a p-value of <0.0001 (table 1). Observations paying with Medicaid were more likely to receive a skeletal survey compared to those with private insurance in crude analysis (1.87 [1.73, 2.01]). Injuries that occurred at home, had a high ISS, and were associated with TBI all high higher odds of receiving a skeletal survey. Observations presenting to pediatric hospitals or teaching hospitals had a higher odds of receiving a skeletal survey as well. In logistic regression analysis, race, primary payment method, location, ISS, TBI, hospital type, and teaching hospital are all statistically significant predictors of receiving a skeletal survey (Table 4). 

CONCLUSIONS: This study suggests there is a screening bias in the workup for non-accidental trauma in children less than one year of age. This bias may lead to over-screening of certain racial and socioeconomic groups and under-screening in others. This is concerning given the high morbidity and mortality associated with victims of physical child abuse, and the high-risk population included in this cohort. This study highlights the importance of screening algorithms and guidelines in the workup of non-accidental trauma in order to reduce missed cases of child abuse and decrease overuse of screening tools due to bias. 

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