Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department

Bindi Naik-Mathuria; Brittany L Johnson; Hannah F Todd; Marcella Donaruma-Kwoh; Angela Bachim; Daniel Rubalcava; Adam M Vogel; Liang Chen; Mauricio A Escobar

doi:10.1016/j.jpedsurg.2023.01.046

Development of the Red Flag Scorecard Screening Tool for Identification of Child Physical Abuse in the Emergency Department

J Pediatr Surg. 2023 Sep;58(9):1789-1795. doi: 10.1016/j.jpedsurg.2023.01.046. Epub 2023 Feb 1.

Authors

Bindi Naik-Mathuria¹, Brittany L Johnson², Hannah F Todd², Marcella Donaruma-Kwoh³, Angela Bachim³, Daniel Rubalcava⁴, Adam M Vogel², Liang Chen⁵, Mauricio A Escobar⁶

Affiliations

¹ Department of Surgery, Division of Pediatric Surgery, University of Texas Medical Branch, Galveston, TX, USA. Electronic address: bnaik@utmb.edu.
² Department of Surgery, Division of Pediatric Surgery, Texas Children's Hospital, Houston, TX, USA.
³ Department of Pediatrics, Section of Public Health and Child Abuse Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
⁴ Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital Baylor College of Medicine, Houston, TX, USA.
⁵ Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA.
⁶ Department of Pediatric Surgery and Pediatric Trauma, Mary Bridge Children's Hospital, Tacoma, WA, USA.

PMID: 36841704
DOI: 10.1016/j.jpedsurg.2023.01.046

Abstract

Background: Child physical abuse (CPA) may have subtle presenting signs and can be challenging to identify, especially at emergency centers that do not treat many children. The purpose of this study is to determine the performance of a simple CPA screening tool to identify children most at risk.

Methods: A screening tool ("Red Flag Scorecard") was developed utilizing available evidence-based presenting findings and expert consensus. Retrospective chart review of children treated for injuries between 2014 and 2018 with suspected or confirmed CPA at a level I pediatric trauma center was then performed to validate the screening tool. Descriptive statistics and chi square tests were used to analyze the data.

Results: Of 408 cases, median age was 7 months and 60% were male. The majority (69%) were under 1 year of age. The most common history finding was delay in seeking care (58%, 236/408; p = <0.0001), the most common physical exam finding was bruising located away from bony prominences (45%, 182/408), and the most common imaging finding was unexplained brain injury (49%, 201/408). The majority, 84% (343/408), had at least 2 history findings. The combination score of at least 2 history findings and 1 physical/imaging finding was most sensitive (79%). The scorecard would have identified 94% of children who presented with no trauma history (198/211).

Conclusion: The Red Flag Scorecard may serve as a quick and effective screening tool to raise suspicion for child physical abuse in emergency centers. Prospective study is planned to validate these results.

Level of evidence: IV.

Keywords: Child abuse; Child physical abuse; Nonaccidental trauma; Red flag; Screening tool.

MeSH terms

Child
Child Abuse* / diagnosis
Emergency Service, Hospital
Female
Humans
Infant
Male
Physical Abuse*
Prospective Studies
Retrospective Studies