Child Abuse

Aka: Child Abuse, Child Maltreatment, Non-Accidental Trauma in Children, Nonaccidental Trauma, Non-accidental Trauma, Pediatric Non-Accidental Trauma, Physical Abuse in Children, TEN-4 Rule

1. See Also
   1. Sexual Abuse in Children
   2. Skeletal Survey
   3. Abusive Head Trauma of Infancy (Shaken Baby Syndrome)
   4. Medical Child Abuse (Munchausen Syndrome by Proxy)
   5. Sex Trafficking
2. Definitions
   1. Child Abuse (Child Maltreatment, U.S. Health and human services definition)
      1. Recent act or failure to act on part of parent or caretaker
      2. Results in death, serious physical or emotional harm, sexual abuse or exploitation or
      3. Imminent risk of serious harm
   2. Nonaccidental Trauma
      1. Any non-accidental physical injury (e.g. biting, hitting, kicking burning) or
      2. A non-accidental action that results in a physical Impairment of a child
   3. Neglect
      1. Parental omissions in care that results in actual or potential harm to a child
      2. Child's basic physical, emotional, educational or medical needs are not met in a consistent pattern
3. Epidemiology
   1. Third leading U.S. cause of death age 1 to 4 years old in 2009
   2. Incidence: 4 to 6 million alleged maltreatment cases referred to U.S. child protection per year
      1. Evidence of maltreatment found in 9 of 1000 children (0.9%) after investigation
   3. Demographics of Child Abuse (based on 1995 data, National Child Abuse and Neglect Data Systems)
      1. Offenders
         1. Parents: 80% of cases
         2. Caretakers at daycare, or nursery school: 2%
         3. Abuse is rarely a single event, but rather one of repeated and increasing Violence
         4. Perpetrators cross all socioeconomic , ethnic, racial, gender and setting boundaries
      2. Types of abuse
         1. Neglect: 52%
         2. Physical abuse: 25%
      3. Ages of abused children
         1. Most abused children are under age 6 months
         2. Age 7 years old or younger: 50%
4. Types: Abuse
   1. Neglect
      1. Most common form of Child Maltreatment, and accounts for 73% of child fatalities
      2. Physical neglect includes inadequate hygiene, nutrition, shelter and clothing
         1. Includes environmental hazard exposure (e.g. ingestions)
         2. Includes inadequate supervision (e.g. abandonment, expulsion)
         3. Includes malnourishment or Failure to Thrive (also impacted by poverty, food insecurity)
      3. Medical neglect is refusing or delaying appropriate medical care
         1. Includes presentations with advanced medical or dental disease (also with low health literacy)
      4. Emotional neglect is inadequate nurturing or affection
         1. Includes exposure to Violence (e.g. Intimate Partner Violence)
         2. Includes permission to abuse Alcohol or drugs
         3. Includes delayed mental health care
   2. Physical abuse (Nonaccidental Trauma)
      1. Any non-accidental physical injury (e.g. biting, hitting, kicking burning) or
      2. A non-accidental action that results in a physical Impairment of a child
   3. Psychological Maltreatment or Emotional Abuse
      1. Repeated patterns of Caregiver behavior or extreme incidents
      2. Children interpret that they are worthless, unloved, unwanted or flawed
   4. Sexual Abuse
      1. See Sexual Abuse in Children
5. Precautions
   1. Child Abuse is a commonly missed diagnosis with potentially devestating consequences
      1. Initially missed abusive Head Injury: 30% of cases
      2. Initially missed abusive Fractures: 20% of cases
      3. Identify Child Abuse early, when it is still associated with minor injury
   2. Consider every injury and illness in a child in the context of the reported history and mechanism
      1. Persistent Vomiting without Diarrhea despite >1-3 days of illness (consider Head Injury)
      2. Falls in under age 3 years old (and especially under age 6 months) should be considered carefully
      3. Consider Consultation with a Child Abuse expert if a presentation raises a red flag
      4. Cardiac Arrest in young children (or ALTE)
6. Pathophysiology
   1. Negative Parenting Behaviors are at risk of progressing to abuse
   2. Emotional abuse is a precursor to physical abuse
   3. Child Maltreatment may significantly impact physical, neurologic and intellectual development
7. Risk Factors
   1. Child
      1. Chronic illness
      2. Behavioral Disorder
      3. Physical Disability
      4. Preterm Infant
      5. Unplanned Pregnancy
   2. Caregiver
      1. Alcohol or Substance Abuse
      2. Victim of abuse (e.g. Intimate Partner Violence)
      3. Mental Illness (e.g. Major Depression)
      4. Criminal History
      5. Young parental age
      6. Low self esteem
      7. Low educational level
      8. Poverty
      9. Poor impulse control
      10. Single parent home
      11. Non-biologically related adult living in the same home
8. History
   1. History of event or injury
      1. Ask a careful history and document specific details
         1. What happened?
         2. Where were you and the child when this happened?
         3. Who else was there?
         4. When did this happen?
         5. What made you concerned?
         6. Why did you not come in sooner?
      2. Ask the patient (if old enough) what happened without parents present in the room
      3. Abusive parents may blame an older sibling or family dog for the injury
      4. Avoid asking leading questions that supply the potential abuser with an excuse
      5. Record the history with specific quotes from children and parents or Caregivers
   2. Perform a Trauma-informed history of the child
      1. Stay seated for the interview
      2. Discuss confidentiality, trust, safety
      3. Ask open-ended questions in a nonjudgemental manner
      4. Explain why sensitive questions (e.g. sex) are asked
   3. Medical History
      1. Maternal pregnancy and perinatal history
      2. Prior injuries or Trauma
      3. Congenital disorders or hospitalizations
      4. Developmental history (milestones met?)
   4. Family History
      1. Bleeding Disorders
      2. Bone disorders (e.g. osteogenesis imperfecta)
      3. Genetic disorders
   5. Social history
      1. Discipline techniques
      2. Child fussiness or hyperactivity
      3. Abuse history in child, siblings or parent (Domestic Violence)
      4. Substance Abuse by others in the same home
      5. Financial or social stressors
      6. Violent Behavior in the home
      7. Criminal history of others in home
      8. Mental health problems of family members
9. Screening: Tools
   1. SPUTOVAMO-R2 Checklist
      1. Any positive answer of 5 questions suggests higher suspicion injury
      2. History consistent with injury, interaction appropriate, parents responded with appropriate measures without delay
   2. Pediatric Hurt Insult Threaten Scream Sex Questionnaire (PedHITSS)
      1. Evaluates for abuse exposure
10. Symptoms: Behavior Indicators of abuse
    1. Wary of adult contact
    2. Brief Resolved Unexplained Event (ALTE, BRUE)
    3. Apprehensive when others cry
       1. Concerned that the crying is their fault
       2. Fear that punishment is occurring and they are next
    4. Behavior extremes
       1. Introverted, isolated, and social withdrawal
       2. Out of control anger, aggressive, violent or oppositional
       3. Unconsolable Crying or Fussy Infant (broad differential)
    5. Unexplained Developmental Delay
       1. Speech Delay
       2. Motor skill delay
    6. Comorbidity
       1. Failure to Thrive
       2. Short Stature
       3. Eating Disorders
       4. Major Depression
       5. Anxiety Disorder
11. Exam
    1. See Child Sexual Abuse
    2. Perform exam with a chaperone present
    3. Avoid interfering with formal evidence exam when indicated
       1. Sexual Assualt Nurse Examiner (SANE) exam
       2. Child Abuse specialist
    4. Height, weight and Head Circumference
    5. Alertness
       1. Decreased Glasgow Coma Scale requires immediate evaluation for serious Head Injury
    6. Scalp exam
       1. Traction Alopecia
       2. Bulging Fontanelle
    7. Ear exam
       1. Bruising or hemotympanum
    8. Mouth Exam
       1. Dental Caries may suggest neglect
       2. Oral Lesion such as torn frenulum, chipped teeth or mucosal lesion (e.g. forced feeding in a Fussy Infant)
       3. Mandible injury associated with grabbing the face or holding the child down
    9. Fundoscopic exam (typically performed by ophthalmology with images obtained)
       1. Retinal Hemorrhages
          1. Specific for abusive Head Injury
          2. Not associated with CPR or accidental injury (except possibly at posterior pole)
    10. Palpate for tenderness or deformity
        1. Scalp, neck, and torso
        2. Extremities
    11. Neurologic Exam
        1. Assess for Closed Head Injury and spinal cord injury
        2. Assess for Altered Level of Consciousness (e.g. Abusive Head Trauma of Infancy)
    12. Skin exam
        1. Bruising or marks
12. Signs
    1. Documentation of exam
       1. Obtain consent if possible (optional)
       2. Photograph all injuries in color
          1. Use a ruler in the photograph to document size
       3. Take two or more pictures (e.g. AP and lateral) each from three different orientations
          1. Full body
          2. Medium range
          3. Close-up
       4. Photograph injuries before treatment
          1. Repeat photographs hours or days later
       5. Patient's face should be included in 1 or more photos
       6. Label each photo with name, date, date of injury
          1. Also record photographer and those present at exam
       7. Seal photos in envelope marked confidential
          1. Maintain chain of custody
       8. Background color
          1. Photograph skin against a blue background
          2. Photograph other areas against a neutral background
       9. Consider ultraviolet light
          1. Accentuates bite wounds
    2. Emotional Abuse Indicators
       1. Speech disorders such as Stuttering or slurred speech
       2. Delayed Physical growth
       3. Failure to Thrive
    3. Physical abuse indicators
       1. Lesions show unusual distribution, location, pattern
          1. Lesions appear as handprint or bite mark
          2. Lesions characteristic of Cigarette burn
          3. Lesions limited to hands and feet
          4. Lesions in various stages of healing
          5. Bruising at bilateral ears (Boxing ears)
       2. Red Flag presentations
          1. Significant delay in seeking care
          2. Story inconsistent with the injury
             1. Infants under 3-4 months of age should not be able to "roll off the bed"
          3. Bruising in infants <6 months old or to Abdomen, ear, neck or in an organized pattern
             1. See TEN-4 Rule below
          4. Atypical Fractures as listed below
             1. Long bone Fractures in non-ambulatory infants
             2. Bucket handle Fractures
             3. Scapula, Sternum, or spinous processs Fractures
       3. Red flag injuries
          1. Rib Fractures (especially posterior Rib Fractures)
             1. Rib Fractures under age 3 years, 82% are Child Abuse
             2. Barsness (2003) J Trauma 54(6): 1107-10 [PubMed]
          2. Retinal Hemorrhage
          3. Subdural Hemorrhage or Subarachnoid Hemorrhage
          4. Complex Skull Fractures
          5. Metaphyseal Fractures (Bucket handle Fractures, corner Fractures)
          6. Fractured Scapula or Sternum
          7. Fractured spinous processes or Vertebral body Fractures
          8. Fractures in various stages of healing
          9. Bruising in non-ambulatory infants (“If they don’t cruise, they don’t Bruise”)
          10. Metaphyseal avulsion Fractures (Bucket-Handle Fracture, metaphyseal Corner or chip Fracture)
              1. Occurs secondary to a Whiplash-like injury of an extremity
              2. Pathognomonic for Child Abuse in infants
              3. Bucket handle Fractures (mataphyseal chip Fractures) are due to forceful twisting or pulling
          11. Oropharyngeal injury in non-mobile infant (e.g. something shoved in mouth to pacify a Crying Infant)
              1. Torn Tongue frenulum injury
              2. Chipped teeth in a non-mobile infant
              3. Oral Mucosal injury
          12. Long bone Fractures in Children age <2 years (especially non-ambulatory infant)
              1. Exception: MVA or other serious witnessed injury
              2. Long bone Fractures in infants are associated with a 20% Incidence of Child Abuse
              3. Bilateral long bone Fractures are higher risk for abuse
              4. Femur Fractures
                 1. Femur Fractures under age 12 months are associated with abuse in 33% of cases
                 2. Femur Fractures over age 12-18 months are associated with abuse in 1.5 to 6.0% of cases
                 3. Metaphyseal Fractures are associated with abuse in 50-75% of cases
                 4. Wood (2004) BMC Pediatr 14:169 [PubMed]
       4. Bruising or marks
          1. Not explained by comorbidity
             1. Bleeding Disorder
             2. Collagen vascular disorder
          2. Not explained by increased mobility of children over 6 months
             1. Expect typical Bruising on the shins, Forearms and forehead in toddlers
             2. Bruising should not occur on the torso without blunt Trauma
             3. Bruising on the ear may be associated with yanking on the child's ear
             4. Bruising should not ooccur on the neck without Strangulation or other intentional injury
          3. Bruising patterns
             1. Belt marks
             2. Cigarette burns
          4. TEN-4 Rule (positive criteria requires additional evaluation)
             1. Bruising on Torso, Ear or Neck (TEN) in a child 4 years old or younger OR
             2. Bruising on any child younger than 4 months (those who don't cruise, don't Bruise)
          5. FACES Rule
             1. Brusing at the frenulum, angle Mandible, cheek, Eyelid or Sclera
          6. References
             1. Pierce (2010) Pediatrics 125(1): 67-74 [PubMed]
13. Signs: Injury Locations
    1. Head and Neck
       1. Skull (1%)
       2. Brain (1%)
       3. Head or scalp (7%)
       4. Face (1%)
       5. Eye (5%)
       6. Nose (1%)
       7. Mouth (1%)
       8. Neck (3%)
    2. Torso
       1. Back (10%)
       2. Chest (5%)
       3. Abdomen (4%)
       4. Genitals or Perineum (2%)
    3. Extremities
       1. Shoulders (3%)
       2. Arms (10%)
       3. Hands or Wrists (4%)
       4. Hips or Buttock (12%)
       5. Thighs (9%)
       6. Legs (8%)
       7. Feet (2%)
14. Signs: Injury Types
    1. Welts
    2. Burns
       1. Consider burn specialist Consultation to discuss burn pattern and circumstances
       2. Take pictures of Burn Injury
    3. Fractures
       1. See Red Flag injuries listed above
       2. Spiral Fractures may not be as pathognomonic for Child Abuse as previously thought
          1. Toddler's Fracture of the tibia are spiral and seen in typical Trauma
       3. Consider repeat xrays in 10-14 days after suspected injury if initial xrays are non-diagnostic
       4. Fractures (aside from Skull Fractures) heal at predictable times and offer forensic evidence
          1. Acute Fractures evident within 4 days of injury
          2. Subperiosteal new bone forms by days 5 to 14
          3. Callus forms by days 10 to 14
       5. Red Flags (see above)
          1. Complex Skull Fractures
          2. Scapula or Sternum Fractures
          3. Rib Fractures (esp. posterior Fractures)
          4. Spinous process Fractures
          5. Metaphyseal avulsion Fractures (Bucket-handle Fractures), esp. around the knees and ankles
          6. Non-ambulatory infant with long bone Fractures
    4. Lacerations
    5. Abrasions
       1. Hour 0-6: Raw surface, oozing blood or clear fluid
       2. Hour 6-24: Dry, erythematous lesion
       3. Hour >24: Scab formation
    6. Bruises
       1. Undress the child for exam (Bruises are commonly missed)
       2. Red Flags (see signs above)
          1. Bilaterally symmetric Bruising, with clear pattern (especially central, e.g, over Abdomen)
          2. Buttocks and back are not typically injured accidentally (even in older children)
          3. Non-ambulatory infants (especially under age 6 months)
             1. Isolated Bruising without other signs of injury
                1. Associated with brain or Abdominal Injury in 50% of cases
             2. Those who don't cruise, rarely Bruise
                1. Sugar (1999) Arch Pediatr Adolesc Med 153: 399-403 [PubMed]
          4. Bruising on Abdomen, neck, ear, under chin
             1. Bruising on the shins, Forearms and forehead are expected in active ambulatory children
       3. Color (listed for historical purpose, it is however unreliable as an indicator of injury timing)
          1. Days 0-2: Swelling and tenderness
          2. Days 2-5: Red, blue or purple coloration
          3. Days 5-7: Greenish hue
          4. Days 7-10: Yellow appearance
          5. Days 10-14: Brown discoloration
          6. Days 14-32: Clear appearance
15. Labs
    1. Coagulation studies
       1. Complete Blood Count, Platelets (extensive Bruising)
       2. Prothrombin Time (INR, extensive Bruising)
       3. Partial thromboplastic time (extensive Bruising)
       4. Consider additional testing as needed (e.g. Fibrinogen, Platelet closure time)
    2. Abdominal Trauma labs
       1. Fecal Occult Blood Testing (Abdominal Trauma)
       2. Liver Function Tests, especially AST and ALT (Abdominal Trauma)
       3. Lipase or amylase (Abdominal Trauma)
       4. Urinalysis with microscopic exam (Abdominal Trauma)
    3. Toxicology
       1. Urine toxicology
    4. Other evaluation to consider
       1. Comprehensive Metabolic Panel
       2. Neonatal Sepsis evaluation
       3. Inborn Errors of Metabolism evaluation
16. Imaging
    1. Red Flags
       1. See Non-Accidental Trauma related Fractures
    2. Skeletal Survey XRays
       1. Avoid single view whole-body XRay or "babygram" (inadequate and not helpful)
       2. Consider transfer to a center skilled in Skeletal Surveys to perform these 20-21 images
       3. See Skeletal Survey for Indications and XRay protocol
       4. Perform in all suspected cases under age 2 years (positive in up to 20% of cases)
          1. Consider in ages 2-5 years old (per AAP guidelines)
          2. Consider repeating in 10-14 days for occult Fracture
       5. Also indicated for unexplained Fracture or Rib Fracture <2 years old
          1. Exceptions: Toddler's Fracture, Distal radius or ulna buckle Fracture
       6. Indicated for any Fracture in <1 year old
          1. Exception: Simple linear Skull Fracture attributable to fall
       7. Oblique rib films may better demonstrate posterior Rib Fractures
    3. Head Imaging
       1. Abusive Head Injury has 20% mortality and serious neurologic sequelae in 60-80%
       2. Indications
          1. Head imaging is indicated in most cases of suspected Child Abuse in younger children (esp. <12 months)
          2. Obtain if suspected Head Injury (e.g. Altered Mental Status, bulging Fontanelle)
          3. Obtain in high risk cases
             1. Age < 6 months
             2. Facial Bruising
             3. Rib Fractures
             4. Multiple Fractures
       3. Imaging Modalities
          1. Skull XRay is not adequate
          2. CT Head
             1. Emergency department in unstable patients (e.g. Altered Level of Consciousness)
             2. Ask for 3-D reconstructions of CT for evaluation of Skull Fractures
          3. MRI Brain
             1. Defer CT in favor of routine MRI Brain in stable, neurologically intact patients (preferred)
             2. May obtain MRI within 3-7 days after initial evaluation
             3. MRI Brain may also be performed acutely in stable patients not requiring sedation for imaging
          4. MRI Cervical Spine
             1. Evaluate for ligamentous Cervical Spine Injury if head imaging demonstrates intracranial injury
    4. Abdominal CT Indications
       1. Increased AST or ALT >80 IU/L (associated with 20% positive Abdominal CT) or
       2. History of being struck in Abdomen or
       3. Exam with abdominal Bruising or tenderness
    5. Other imaging to consider
       1. Bone scan
          1. Demonstrate occult Fracture up to 2 weeks after injury
17. Differential Diagnosis
    1. See Inconsolable Crying in Infants
    2. See Seizure Causes
    3. Altered Mental Status
       1. Abusive Head Trauma of Infancy (Shaken Baby Syndrome)
       2. Sepsis
       3. Metabolic Disorders (e.g. Inborn Errors of Metabolism)
       4. Birth Trauma
    4. Abusive Bruise mimics
       1. Dermal Melanocytes (Mongolian Spot)
       2. Idiopathic Thrombocytopenic Purpura
       3. Henoch-Schonlein Purpura
       4. Ehlers-Danlos Syndrome
       5. Leukemia
       6. Hematologic Disorders
    5. Abusive Fracture mimics
       1. Osteogenesis imperfecta
       2. Osteopenia of prematurity or chronic illness
       3. Vitamin D Dependent Rickets
       4. Menkes Syndrome (kinky hair syndrome)
       5. Birth Trauma
       6. Congenital Syphilis
18. Prognosis
    1. Undiagnosed Child Abuse is associated with 25% mortality rate in 2 years
    2. Child Abuse strong risk factor for adult crime behavior
       1. 908 cases of Child Abuse 1967-1971 in midwest
          1. followed arrest record through mid-1994
       2. Significantly higher rate of crime and of Violence
       3. African American Males had much higher risks
       4. Maxfield (1996) Arch Pediatr Adolesc Med 150:390-5 [PubMed]
    3. Investigation Results
       1. 58% of investigations were found not substantiated
       2. 36% were found substantiated or maltreatment present
       3. National Child Abuse and Neglect Data Systems [PubMed]
    4. Protective Factors
       1. Child with above average cognition
       2. Child's belief in own ability to control their destiny
       3. Child's self impulse control and modulation
       4. Child's high self esteem and sense of self worth
       5. Child involvement in extracurricular activities or hobbies
       6. Spirituality or involvement in religious community
       7. Caregiver Support network
19. Management
    1. Report all cases of suspected Child Abuse (medical providers are mandated reporters)
       1. Contact local social services
    2. Consultations
       1. Ophthalmology for dilated Eye Exam (all cases age<2 years)
          1. Evaluate for Retinal Hemorrhages, typically with Retinal images obtained
          2. Significant Retinal Hemorrhages are extremely rare with accidental Trauma
       2. Dental Consultation (if bite present to find source)
       3. Burn specialist (if Burn Injury present)
    3. Keep careful and accurate documentation
       1. See Exam above
    4. Consider hospitalization for evaluation and treatment of Child Abuse or neglect
       1. Consult tertiary Child Abuse resources
    5. Approach to accompanying adult with child
       1. Develop initial rapport with child and adults
       2. State role as the advocate of the child, and mandated duty to report concerns
       3. Avoid confrontational tone
       4. Ask adults accompanying child to step out for child's interview (if age allows a history)
       5. Describe the red flags: "This injury is more severe than what we would expect from this fall"
       6. Describe the medical reasons for evaluation
          1. "We do not want to miss a serious underlying cause for brittle bones"
       7. Describe the Non-accidental Trauma concern
          1. "We do not want to miss Trauma that you are unaware of, or that someone is trying to harm your child"
       8. Describe the evaluation
          1. "We need to check XRays and CT to look for other injuries and to check blood tests to look for other disorders"
       9. Explain the need to involve other agencies to ensure safety
          1. Notify accompanying adults when involving police or child protection
          2. Do not notify adults if child is returning home with them (may put the child in danger of escalating injury)
20. Complications
    1. High Risk Behaviors
       1. High risk sexual behavior (Sexually Transmitted Infection, Unplanned Pregnancy)
       2. Substance Abuse
       3. Revictimization
    2. Secondary medical conditions
       1. Fibromyalgia
       2. Irritable Bowel Syndrome
       3. Obesity
    3. Secondary mental health conditions
       1. Major Depression
       2. Anxiety Disorder
       3. Posttraumatic Stress Disorder
21. Prevention
    1. Inquire about social history at clinic visits
    2. Teach Positive Parenting Techniques
       1. Positive Parenting Program (Triple-P)
       2. Home Visitation Programs for high risk parents (e.g. Nurse Family Partnership, Healthy Families America, MESCH)
       3. Discipline Without Shouting or Spanking (book by Unell and Wyckoff)
    3. Address parental frustrations
       1. Discuss parental coping skills
       2. Offer anticipatory guidance for challenges at each developmental stage
       3. Discuss response and coping with child crying
       4. Discuss Discipline techniques
    4. Anticipate children at higher risk for abuse
       1. Discuss respite care for children with disabilities
    5. Be alert for parental risk factors for abuse
       1. Intimate Partner Violence
       2. Postpartum Depression
    6. Early intervention if emotional abuse suspected
22. Resources
    1. Child Welfare Information Gateway
       1. http://www.childwelfare.gov
    2. ChildHelp USA
       1. http://childhelpusa.org
    3. Tennyson Center for Children
       1. http://www.childabuse.org
    4. Child Abuse Evaluation and Treatment Medical Providers
       1. http://www.ChildAbuseMD.com
23. References
    1. Gardiner (2018) Crit Dec Emerg Med 37(5): 3-14
    2. Claudius, Behar and Lindberg in Herbert (2014) EM:Rap 14(1):14-16
    3. Pomeranz (2015) Crit Dec Emerg Med 29(7): 2-9
    4. Pomeranz (2021) Crit Dec Emerg Med 35(1): 3-10
    5. Swaminathan and Horowitz in Herbert (2019) EM:Rap 19(6):16
    6. (2000) Pediatrics 105:1345-8 [PubMed]
    7. Kocher (2000) J Am Acad Orthop Surg 8:10-20 [PubMed]
    8. Kodner (2013) Am Fam Physician 88(10): 669-75 [PubMed]
    9. Lane (2003) Clin Fam Pract 5:493-514 [PubMed]
    10. McDonald (2007) Am Fam Physician 75:221-8 [PubMed]
    11. Suniega (2022) Am Fam Physician 105(5): 521-8 [PubMed]