title: Duodenal injuries in the very young: child abuse?
abstract: BACKGROUND
  Duodenal injuries in children are uncommon but have been specifically linked with child abuse in case reports. Owing to the rarity of the diagnosis, few studies to date have looked at the association between duodenal injuries and mechanism in younger child. We hypothesize that duodenal injuries in the very young are significantly associated with child abuse.
  
  
  METHODS
  This investigation is a retrospective cohort study of patients admitted with duodenal injuries at one of six Level I pediatric trauma centers. All institutions had institutional review board approval. The trauma registries were used to identify children aged 0 year to 5 years from 1991 to 2011. Multiple variables were collected and included age, mechanism of injury, type of duodenal injury, additional injuries, mortality, and results of abuse investigation if available. Relationships were analyzed using Fischer's exact test.
  
  
  RESULTS
  We identified 32 patients with duodenal injuries with a mean age of 3 years. Duodenal injuries included duodenal hematomas (44%) and perforations/transections (56%). Of all duodenal injuries, 53% resulted in operation, 53% had additional injuries, and 12.5% resulted in death. Of the 32 children presenting with duodenal injuries, 20 were child abuse patients (62.5%). All duodenal injuries in children younger than 2 years were caused by child abuse (6 of 6, p = 0.06) and more than half of the duodenal injuries in children older than 2 years were caused by child abuse (14 of 26). Child abuse-related duodenal injuries were associated with delayed presentation (p = 0.004). There was a significant increase in child abuse-related duodenal injuries during the time frame of the study (p = 0.002).
  
  
  CONCLUSIONS
  Duodenal injuries are extremely rare in the pediatric population. This multi-institutional investigation found that child abuse consistently associated with duodenal injuries in children younger than 2 years. The evidence supports a child abuse investigation on children younger than 2 years with duodenal injury.
  
  
  METHODS
  Epidemiological study, level III.
authors.affiliation: Trauma Services, Dell Children's Medical Center of Central Texas, Department of Surgery University of Texas Southwestern Medical School, Austin, Texas, USA.
authors.forename: Lauren
authors.initials: L
authors.lastname: Sowrey
authors.forename: Karla A
authors.initials: KA
authors.lastname: Lawson
authors.forename: Pamela
authors.initials: P
authors.lastname: Garcia-Filion
authors.forename: David
authors.initials: D
authors.lastname: Notrica
authors.forename: David
authors.initials: D
authors.lastname: Tuggle
authors.forename: James W
authors.initials: JW
authors.lastname: Eubanks
authors.forename: Robert Todd
authors.initials: RT
authors.lastname: Maxson
authors.forename: John
authors.initials: J
authors.lastname: Recicar
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Megison
authors.forename: Nilda M
authors.initials: NM
authors.lastname: Garcia
mesh_terms: D000059:Accidents; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D004386:Duodenum / Q000293:injuries*; D005260:Female; D006801:Humans; D007223:Infant; D007416:Intestinal Perforation / Q000175:diagnosis / Q000209:etiology; D008297:Male