Eliminating disparity in evaluation for abuse in infants with head injury: use of a screening guideline

J Pediatr Surg. 2009 Jun;44(6):1229-34; discussion 1234-5. doi: 10.1016/j.jpedsurg.2009.02.044.


Purpose: Minority and disadvantaged children are evaluated for nonaccidental trauma (NAT) at higher rates than other children. At our institution, we implemented a guideline to perform skeletal surveys to screen for occult fractures in all infants with unwitnessed head injury (UHI). The goal was to determine if this guideline decreased disparities in the screening of African American (AA) and uninsured children.

Patients and methods: For 54 months, rates of skeletal surveillance and abuse determination were compared between AA and white infants admitted with UHI before and after implementation of our guideline. Logistic regression was used to control for confounders.

Results: Before the guideline, AAs underwent skeletal surveillance more than whites (n = 208; 90.5% vs 69.3%; P = .01), with 20% of screened infants determined to be probable victims of NAT. Whites with private insurance were less likely to be screened compared to those without private insurance (50.0% vs 88.1%; P < .001). After the guideline, AA and whites were surveyed equally (n = 52; 92.3% vs 84.6%; P = 1.0), with 22% found to be probable cases of NAT.

Conclusions: This is the first report of a successful policy-based intervention to decrease disparity in care. The maintenance of a stable rate of NAT determination despite increased screening suggests more victims of abuse may be identified with guideline use, and therefore, this may be an additional benefit of the guideline.

MeSH terms

  • African Americans
  • Algorithms
  • Bone and Bones / diagnostic imaging*
  • Child Abuse / diagnosis*
  • Craniocerebral Trauma / diagnosis*
  • European Continental Ancestry Group
  • Female
  • Healthcare Disparities
  • Humans
  • Infant
  • Infant, Newborn
  • Insurance Coverage
  • Male
  • Mass Screening
  • Medically Uninsured
  • Radiography