Document Type
Article
Publication Date
4-2026
Identifier
DOI: 10.1016/j.acap.2025.103196
Abstract
OBJECTIVE: Many young children with isolated skull fractures are referred to child protective services (CPS) despite being assessed to have a low likelihood of abuse. We sought to identify factors associated with CPS referrals in this population and to quantify hospital-level variation.
METHODS: We performed a multicenter retrospective cross-sectional study of children < 2 years with skull fractures with or without a small underlying intracranial hemorrhage (ICH) and no additional injuries undergoing a child abuse pediatrics (CAP) subspecialty evaluation. We explored associations between demographic factors, clinical characteristics, psychosocial risk factors, and hospital site with CPS referral status. We performed multivariable logistic regression, adjusting for transfer status and all significant covariates from unadjusted analyses. We utilized marginal standardization to calculate the estimated probability of CPS referrals at each site, adjusting for all factors in the final model.
RESULTS: Of 528 children, 303 (57.4%) were referred to CPS, with 86.5% referred before CAP consultation. In multivariable logistic regression, presence of psychosocial risk factors (OR 4.00; 95% CI 2.25, 7.11), in-person CAP consult (OR 3.93; 1.61, 9.62), inflicted or no trauma history provided (OR 6.15; 3.30, 11.45), absence of ICH (OR 2.03; 1.26, 3.27), and site were significantly associated with CPS referral. After adjustment for case-mix, the percentage of children referred to CPS ranged from 34.6% to 76.4% across sites.
CONCLUSIONS: We found a twofold variation in CPS referrals based on site. Most referrals occurred before CAP involvement. These findings support the need for increased guidance regarding indications for referral.
Journal Title
Acad Pediatr
Volume
26
Issue
3
First Page
103196
Last Page
103196
MeSH Keywords
Humans; Referral and Consultation; Male; Cross-Sectional Studies; Female; Retrospective Studies; Infant; Child Abuse; Child Protective Services; Skull Fractures; Risk Factors; Logistic Models; Intracranial Hemorrhages; Multivariate Analysis
PubMed ID
41338466
Keywords
CAPNET; child abuse; child protective services; skull fracture
Recommended Citation
Breeden-Carino K, Wood JN, Christian CW, et al. Factors Associated With Child Protective Services Referrals in Young Children With Isolated Skull Fractures. Acad Pediatr. 2026;26(3):103196. doi:10.1016/j.acap.2025.103196
Comments
This article is available under the Creative Commons CC-BY-NC-ND license and permits non-commercial use of the work as published, without adaptation or alteration provided the work is fully attributed.
Publisher's Link: https://www.academicpedsjnl.net/article/S1876-2859(25)00421-8/fulltext