Factors Associated With Child Protective Services Referrals in Young Children With Isolated Skull Fractures

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.