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Lane WG, Rubin DM, Monteith R, Christian CW. Racial Differences in the Evaluation of Pediatric Fractures for Physical Abuse. JAMA. 2002;288(13):1603–1609. doi:10.1001/jama.288.13.1603
Author Affiliations: Division of General Pediatrics, Children's Hospital of Philadelphia (Drs Lane, Rubin, and Christian) and University of Pennsylvania School of Medicine (Drs Lane, Rubin, Monteith, and Christian), Philadelphia. Dr Lane is now with the Departments of Pediatrics and Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore. Dr Monteith is now with Childrens National Medical Center, Washington, DC.
Context Child maltreatment is a significant problem within US society, and minority
children have higher rates of substantiated maltreatment than do white children.
However, it is unclear whether minority children are abused more frequently
than whites or whether their cases are more likely to be reported.
Objectives To determine whether there are racial differences in the evaluation
and Child Protective Services (CPS) reporting of young children hospitalized
Design, Setting, and Patients Retrospective chart review conducted at an urban US academic children's
hospital among 388 children younger than 3 years hospitalized for treatment
of an acute primary skull or long-bone fracture between 1994 and 2000. Children
with perpetrator-admitted child abuse, metabolic bone disease, birth trauma,
or injury caused by vehicular crash were excluded.
Main Outcome Measures Ordering of skeletal surveys and filing reports of suspected abuse.
Results Reports of suspected abuse were filed for 22.5% of white and 52.9% of
minority children (P<.001). Abusive injuries,
as determined by expert review, were more common among minority children than
among white children (27.6% vs 12.5%; P<.001).
Minority children aged at least 12 months to 3 years (toddlers) were significantly
more likely to have a skeletal survey performed compared with their white
counterparts, even after controlling for insurance status, independent expert
determination of likelihood of abuse, and appropriateness of performing a
skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI],
3.48-22.03; P<.001). This group of children was
also more likely to be reported to CPS compared with white toddlers, even
after controlling for insurance status and likelihood of abuse (adjusted OR,
4.32; 95% CI, 1.63-11.43; P = .003). By likelihood
of abuse, differential ordering of skeletal surveys and reporting of suspected
abuse were most pronounced for children at least 12 months old with accidental
injuries; however, differences were also noted among toddlers with indeterminate
injuries but not among infants or toddlers with abusive injuries. Minority
children at least 12 months old with accidental injuries were more than 3
times more likely than their white counterparts to be reported for suspected
abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08;
95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI,
Conclusion While minority children had higher rates of abusive fractures in our
sample, they were also more likely to be evaluated and reported for suspected
abuse, even after controlling for the likelihood of abusive injury. This suggests
that racial differences do exist in the evaluation and reporting of pediatric
fractures for child abuse, particularly in toddlers with accidental injuries.
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