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Wood JN, Campbell KA, Anderst JD, Bachim AN, Berger RP, Hymel KP, Harper NS, Letson MM, Melville JD, Okunowo O, Lindberg DM. Child Abuse Pediatrics Research Network: The CAPNET Core Data Project. Acad Pediatr 2023; 23:402-409. [PMID: 35840086 PMCID: PMC9834430 DOI: 10.1016/j.acap.2022.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/01/2022] [Accepted: 07/04/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network. METHODS We conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021. RESULTS Among 3667 patients with 3721 encounters, 69.4% were <3 years old; 44.3% <1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPs performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild/intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse. CONCLUSION Most children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.
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Affiliation(s)
- Joanne N Wood
- Division of General Pediatrics and PolicyLab (JN Wood), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Roberts Center for Pediatric Research, Philadelphia, Pa.
| | - Kristine A Campbell
- Department of Pediatrics (KA Campbell), University of Utah, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, Utah
| | - James D Anderst
- Children's Mercy Kansas City (JD Anderst), University of Missouri Kansas City School of Medicine, Kansas City, Mo
| | - Angela N Bachim
- Division of Public Health Pediatrics, Department of Pediatrics (AN Bachim), Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Rachel P Berger
- Department of Pediatrics (RP Berger), UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pa
| | - Kent P Hymel
- Penn State Health Children's Hospital, Penn State College of Medicine (KP Hymel), Hershey, Pa
| | - Nancy S Harper
- University of Minnesota School of Medicine, Center for Safe and Healthy Children (NS Harper), Minneapolis, Minn
| | - Megan M Letson
- Nationwide Children's Hospital (M Letson), The Ohio State University College of Medicine, Columbus, Ohio
| | - John D Melville
- Division of Child Abuse Pediatrics (JD Melville), Medical University of South Carolina, Charleston, SC
| | - Oluwatimilehin Okunowo
- Data Science & Biostatistics Unit, Department of Biomedical and Health Informatics (O Okunowo), Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, Philadelphia, Pa
| | - Daniel M Lindberg
- Department of Emergency Medicine, The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect (DM Lindberg), University of Colorado School of Medicine, Aurora, Colo
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Rasooly IR, Khan AN, Aldana Sierra MC, Shankar M, Dang K, Cao L, Wood JN. Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children. Acad Pediatr 2023; 23:396-401. [PMID: 35777658 PMCID: PMC10228836 DOI: 10.1016/j.acap.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/10/2022] [Accepted: 06/20/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse. METHODS We extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed. RESULTS Of 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80-0.99) for T74.12 "Adult and child abuse, neglect, and other maltreatment, confirmed" to 0.24 (95% CI: 0.06-0.42) for Z04.72 "Encounter for examination and observation following alleged child physical abuse." CONCLUSIONS ICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.
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Affiliation(s)
- Irit R Rasooly
- Division of General Pediatrics, Children's Hospital of Philadelphia (IR Rasooly, MC Aldana Sierra, M Shankar, K Dang, JN Wood), Philadelphia, Pa; Center for Pediatric Clinical Effectiveness & PolicyLab, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research (IR Rasooly, JN Wood), Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (IR Rasooly, K Dang, JN Wood), Philadelphia, Pa; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia (IR Rasooly, A Khan, L Cao), Philadelphia, Pa.
| | - Amina N Khan
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia (IR Rasooly, A Khan, L Cao), Philadelphia, Pa; Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia (A Khan), Philadelphia, Pa
| | - Maria C Aldana Sierra
- Division of General Pediatrics, Children's Hospital of Philadelphia (IR Rasooly, MC Aldana Sierra, M Shankar, K Dang, JN Wood), Philadelphia, Pa; Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia (MC Aldana Sierra, JN Wood), Philadelphia, Pa
| | - Michelle Shankar
- Division of General Pediatrics, Children's Hospital of Philadelphia (IR Rasooly, MC Aldana Sierra, M Shankar, K Dang, JN Wood), Philadelphia, Pa
| | - Khoi Dang
- Division of General Pediatrics, Children's Hospital of Philadelphia (IR Rasooly, MC Aldana Sierra, M Shankar, K Dang, JN Wood), Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (IR Rasooly, K Dang, JN Wood), Philadelphia, Pa
| | - Lusha Cao
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia (IR Rasooly, A Khan, L Cao), Philadelphia, Pa
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia (IR Rasooly, MC Aldana Sierra, M Shankar, K Dang, JN Wood), Philadelphia, Pa; Center for Pediatric Clinical Effectiveness & PolicyLab, Children's Hospital of Philadelphia, Roberts Center for Pediatric Research (IR Rasooly, JN Wood), Philadelphia, Pa; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania (IR Rasooly, K Dang, JN Wood), Philadelphia, Pa; Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia (MC Aldana Sierra, JN Wood), Philadelphia, Pa
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Anderst J, Carpenter SL, Abshire TC, Killough E, Mendonca EA, Downs SM, Wetmore C, Allen C, Dickens D, Harper J, Rogers ZR, Jain J, Warwick A, Yates A, Hord J, Lipton J, Wilson H, Kirkwood S, Haney SB, Asnes AG, Gavril AR, Girardet RG, Heavilin N, Gilmartin ABH, Laskey A, Messner SA, Mohr BA, Nienow SM, Rosado N, Idzerda SM, Legano LA, Raj A, Sirotnak AP, Forkey HC, Keeshin B, Matjasko J, Edward H, Chavdar M, Di Paola J, Leavey P, Graham D, Hastings C, Hijiya N, Hord J, Matthews D, Pace B, Velez MC, Wechsler D, Billett A, Stork L, Hooker R. Evaluation for Bleeding Disorders in Suspected Child Abuse. Pediatrics 2022; 150:189510. [PMID: 36180615 DOI: 10.1542/peds.2022-059276] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
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Affiliation(s)
- James Anderst
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Shannon L Carpenter
- Division of Hematology/Oncology/BMT, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Thomas C Abshire
- Senior Investigator Emeritus, Versiti Blood Research Institute, Department of Pediatrics, Medicine, and the CT SI of Southeast Wisconsin, Emeritus, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Emily Killough
- Division of Child Adversity and Resilience, Children's Mercy Hospital, Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri
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Negriff S, DiGangi MJ, Sharp AL, Wu J. Injuries Associated With Subsequent Child Maltreatment Diagnosis: By Age, Race, Gender, and Medicaid Status. CHILD MALTREATMENT 2022; 27:225-234. [PMID: 34315243 DOI: 10.1177/10775595211031385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This study examined injuries that may precede a child maltreatment (CM) diagnosis, by age, race/ethnicity, gender, and Medicaid status using a retrospective case-control design among child members of a large integrated healthcare system (N = 9152 participants, n = 4576 case). Injury categories based on diagnosis codes from medical visits were bruising, fractures, lacerations, head injury, burns, falls, and unspecified injury. Results showed that all injury categories were significant predictors of a subsequent CM diagnosis, but only for children < 3 years old. Specifically, fracture and head injury were the highest risk for a subsequent CM diagnosis. All injury types were significant predictors of maltreatment diagnosis for Hispanic children < 3 years, which was not the case for the other race/ethnicities. Overall, these findings suggest that all types of injury within these specific categories should have a more thorough assessment for possible abuse for children under 3 years. This work can inform the development of clinical decision support tools to aid healthcare providers in detecting abusive injuries.
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Affiliation(s)
- Sonya Negriff
- Department of Research & Evaluation, 166700Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Mercie J DiGangi
- Department of Pediatrics, 166700Kaiser Permanente Southern California, Bellflower, CA, USA
| | - Adam L Sharp
- Department of Research & Evaluation, 166700Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jun Wu
- Department of Research & Evaluation, 166700Kaiser Permanente Southern California, Pasadena, CA, USA
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Eismann EA, Shapiro RA, Makoroff KL, Theuerling J, Stephenson N, Duma EM, Fain ET, Frey TM, Riney LC, Thackeray JD. Identifying Predictors of Physical Abuse Evaluation of Injured Infants: Opportunities to Improve Recognition. Pediatr Emerg Care 2021; 37:e1503-e1509. [PMID: 32433455 DOI: 10.1097/pec.0000000000002100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To identify predictors of physical abuse evaluation in infants younger than 6 months with visible injury and to determine the prevalence of occult fracture and intracranial hemorrhage in those evaluated. METHODS Infants 6.0 months or younger who presented with visible injury to a pediatric hospital-affiliated emergency department or urgent care between July 2013 and January 2017 were included. Potential predictors included sociodemographics, treatment site, provider, injury characteristics, and history. Outcome variables included completion of a radiographic skeletal survey and identification of fracture (suspected or occult) and intracranial hemorrhage. RESULTS Visible injury was identified in 378 infants, 47% of whom did not receive a skeletal survey. Of those with bruising, burns, or intraoral injuries, skeletal survey was less likely in patients 3 months or older, of black race, presenting to an urgent care or satellite location, evaluated by a non-pediatric emergency medicine-trained physician or nurse practitioner, or with a burn. Of these, 25% had an occult fracture, and 24% had intracranial hemorrhage. Occult fractures were also found in infants with apparently isolated abrasion/laceration (14%), subconjunctival hemorrhage (33%), and scalp hematoma/swelling (13%). CONCLUSIONS About half of preambulatory infants with visible injury were not evaluated for physical abuse. Targeted education is recommended as provider experience and training influenced the likelihood of physical abuse evaluation. Occult fractures and intracranial hemorrhage were often found in infants presenting with seemingly isolated "minor" injuries. Physical abuse should be considered when any injury is identified in an infant younger than 6 months.
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Affiliation(s)
- Emily A Eismann
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | | | | | - Jack Theuerling
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | - Nicole Stephenson
- From the Mayerson Center for Safe and Healthy Children, Cincinnati Children's Hospital Medical Center
| | | | | | - Theresa M Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Lauren C Riney
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Marine MB. A call to action: education of radiology residents in child abuse imaging. Pediatr Radiol 2021; 51:695-696. [PMID: 33666734 DOI: 10.1007/s00247-021-05012-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Megan B Marine
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Drive, Room 1053, Indianapolis, IN, 46202, USA.
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Parker J, McMillan L, Olson S, Ruppel S, Vieth V. Responding to Basic and Complex Cases of Child Abuse: a Comparison Study of Recent and Current Child Advocacy Studies (CAST) Students with DSS Workers in the Field. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2020; 13:357-364. [PMID: 33269036 PMCID: PMC7683666 DOI: 10.1007/s40653-019-00297-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In an effort to improve the training of future child protection professionals, more than 70 universities and graduate schools in the United States have implemented Child Advocacy Studies (CAST) minors or graduate programs. In order to assess the efficacy of these programs, 46 current and recent graduates of a CAST minor and 43 child protection professionals currently employed by a Department of Social Services (DSS) were given two vignettes. The first vignette involved a clear case of sexual abuse and the second vignette involved a more complex case involving polyvictimization. The students were asked to identify various systems that needed to be involved, potential corroborating evidence, risk and protective factors, and types of victimization. In the case of sexual abuse, the current CAST students and CAST graduates performed at the same level as DSS caseworkers. On the more complex polyvictimization scenario, the current CAST students and CAST graduates performed significantly better than all levels of DSS caseworkers in identifying systems that respond to child maltreatment and in identifying psychological and emotional abuse. The results of this study suggests that undergraduate CAST minors may be an effective model for improving the knowledge and skills of future child protection professionals in responding to complex cases of maltreatment.
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Affiliation(s)
- Jennifer Parker
- Child Protection Training Center, University of South Carolina Upstate, 160 E. St. John Street, Spartanburg, SC 29306 USA
| | - Lynn McMillan
- Center for Child Advocacy Studies, University of South Carolina Upstate, Spartanburg, SC USA
| | - Stacey Olson
- Center for Child Advocacy Studies, University of South Carolina Upstate, Spartanburg, SC USA
| | - Susan Ruppel
- Child Protection Training Center, University of South Carolina Upstate, 160 E. St. John Street, Spartanburg, SC 29306 USA
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Chahla S, Ortega H. Intracranial Injury Among Children with Abuse-Related Long Bone Fractures. J Emerg Med 2020; 59:735-743. [PMID: 32682640 PMCID: PMC7364151 DOI: 10.1016/j.jemermed.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/13/2020] [Accepted: 06/01/2020] [Indexed: 11/03/2022]
Abstract
Background Objectives Methods Results Conclusions
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9
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Shaw J, Simonton K. Pediatric Fractures: Identifying and Managing Physical Abuse. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Krawiec C, Gerard S, Iriana S, Berger R, Levi B. What We Can Learn From Failure: An EHR-Based Child Protection Alert System. CHILD MALTREATMENT 2020; 25:61-69. [PMID: 31137955 DOI: 10.1177/1077559519848845] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This study aimed to evaluate the efficacy of a newly implemented Child Protection Alert System (CPAS) that utilizes triggering diagnoses to identify children who have been confirmed/strongly suspected as maltreated. We retrospectively reviewed electronic health records (EHRs) of 666 patients evaluated by our institution's child protection team between 2009 and 2014. We examined each EHR for the presence of a pop-up alert, a persistent text-based visual alert, and diagnoses denoting child maltreatment. Diagnostic accuracy of the CPAS for child maltreatment identification was assessed. Of 323 patients for whom child maltreatment was confirmed/strongly suspected, 21.7% (70/323) had a qualifying longitudinal diagnosis listed. The pop-up alert fired in 14% of cases (45/323) with a sensitivity and specificity of 13.9% (95% CI [10.4%, 18.2%]) and 100% (95% CI [98.9%, 100.0%]), respectively. The text-based visual alert displayed in 44 of 45 cases. The CPAS is a novel simple way to support clinical decision-making to identify and protect children at risk of (re)abuse. This study highlights multiple barriers that must be overcome to effectively design and implement a CPAS to protect at-risk children.
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Affiliation(s)
- Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Children's Hospital, Hershey, PA, USA
| | - Seth Gerard
- Emergency Medicine, York Hospital, York, PA, USA
| | - Sarah Iriana
- Department of Pediatrics, General Academic Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Rachel Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin Levi
- Department of Pediatrics, General Academic Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
- Department of Humanities, Penn State College of Medicine, Hershey, PA, USA
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Stavas N, Paine C, Song L, Shults J, Wood J. Impact of Child Abuse Clinical Pathways on Skeletal Survey Performance in High-Risk Infants. Acad Pediatr 2020; 20:39-45. [PMID: 30880065 PMCID: PMC7898241 DOI: 10.1016/j.acap.2019.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/29/2019] [Accepted: 02/10/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought: 1) to examine the association between the presence of a child abuse pathway and the odds of skeletal survey performance in infants with injuries associated with high risk of abuse and 2) to determine whether pathway presence decreased disparities in skeletal survey performance. METHODS: In this retrospective study of children <1 year diagnosed with injuries associated with high risk of abuse at hospitals in the Pediatric Hospital Information System, information regarding the presence of a child abuse pathway was collected via survey. We examined whether the presence of a child abuse pathway was associated with the odds of obtaining a skeletal survey, adjusting for patient-level factors. RESULTS: Among 2085 included cases 55% were male, 69% had public insurance, and 64% were white. Fifty-eight percent presented to a hospital when a pathway was present. Skeletal surveys were performed in 86% of children between 0 and 5 months and 73% of children 6-11 months. In our regression model, adjusted for covariates (age, race, insurance, injury) the presence of a child abuse pathway in a hospital was associated with greater odds of skeletal survey performance (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.02-2.08). Children with public insurance had greater odds of receiving a skeletal survey (OR 2.75, 95% CI 2.11-3.52) despite presence of pathway. CONCLUSIONS: When a child abuse clinical pathway was present, children with injuries associated with a high risk of abuse had a greater odds of receiving a skeletal survey. Differences in skeletal survey performance exist between infants with public vs. private insurance regardless of a pathway.
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Affiliation(s)
- Natalie Stavas
- Division of General Pediatrics (N Stavas and J Wood); Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania (N Stavas and J Wood), Philadelphia.
| | - Christine Paine
- Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia
| | - Justine Shults
- Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia
| | - Joanne Wood
- Division of General Pediatrics (N Stavas and J Wood); Center for Pediatric Clinical Effectiveness and PolicyLab (N Stavas, C Paine, L Song, J Shults, and J Wood), The Children's Hospital of Philadelphia; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania (N Stavas and J Wood), Philadelphia
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Zins ZP, Wheeler KK, Brink F, Armstrong M, Shi J, Groner JI, Xiang H. Trends in US physician diagnosis of child physical abuse and neglect injuries, 2006-2014. CHILD ABUSE & NEGLECT 2019; 98:104179. [PMID: 31704543 DOI: 10.1016/j.chiabu.2019.104179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/30/2019] [Accepted: 09/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine if US child physical abuse and neglect injury rates changed from 2006 to 2014, whether definitive diagnoses of physical abuse and neglect were used more often over time, and what patient factors influenced definitive physical maltreatment diagnoses. METHODS Nationally estimated rates of definitive and suggestive physical abuse and neglect injuries for children <10 years were generated using the Nationwide Emergency Department Sample, the National Inpatient Sample, and census estimates. Trends over time were evaluated, including the trend in the proportion of definitive diagnoses to all diagnoses (definitive plus suggestive). Logistic regression was used to evaluate whether patient characteristics and hospital patient volumes were associated with definitive versus suggestive diagnoses. RESULTS The population rates of child physical maltreatment medically treated injuries were unchanged from 2006 to 2014; the trends were not statistically significant for ED or hospitalized patients. Over time, physician definitive diagnoses as a proportion of all physical maltreatment diagnoses (definitive plus suggestive) increased in admitted children from 17.6% in 2006 to 22.0% in 2014 (p = 0.02). Older age, white race, lower income by zip code, and public insurance as well as larger patient volumes increased the odds of definitive rather than suggestive diagnoses of physical abuse and neglect injuries. CONCLUSIONS Definitive diagnoses of physical abuse and neglect increased over the study period and were associated with hospital volume and patient characteristics which may reflect provider experience and possible bias. The use of electronic medical records may have influenced the coding of definitive diagnoses.
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Affiliation(s)
- Zachary P Zins
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Krista K Wheeler
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Farah Brink
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA; The Center for Family Safety and Healing, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Megan Armstrong
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Junxin Shi
- Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Jonathan I Groner
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA; Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Trauma Program, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Henry Xiang
- The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA; Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Center for Injury Research and Policy, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
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Mitchell PD, Brown R, Wang T, Shah RD, Samworth RJ, Deakin S, Edge P, Hudson I, Hutchinson R, Stohr K, Latimer M, Natarajan R, Qasim S, Rehm A, Sanghrajka A, Tissingh E, Wright GM. Multicentre study of physical abuse and limb fractures in young children in the East Anglia Region, UK. Arch Dis Child 2019; 104:956-961. [PMID: 30636223 DOI: 10.1136/archdischild-2018-315035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 12/06/2018] [Accepted: 12/08/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine if the detection of physical abuse in young children with fractures is of uniform high standard in the East Anglia Region of the UK, and whether we can identify areas for improvement in our detection of high-risk groups. DESIGN Multicentre retrospective 4-year study. SETTING 7 hospitals across the East Anglia Region of Britain (East Anglia Paediatric Physical Abuse and Fractures study). PARTICIPANTS Age groups and fractures indicated as being at higher risk for physical abuse (all children under 12 months of age, and fractures of humerus and femur in children under 36 months of age). OUTCOME MEASURES Our criterion for physical abuse was the decision of a multiagency child protection case conference (CPCC). RESULTS Probability of CPCC decision of physical abuse was highest in infants, ranging from 50% of fractures sustained in the first month of life (excluding obstetric injuries) to 10% at 12 months of age. Only 46%-86% of infants (under 12 months) with a fracture were assessed by a paediatrician for physical abuse after their fracture. Significant variation in the use of skeletal surveys and in CPCC decision of physical abuse was noted in children attending different hospitals. CONCLUSIONS It is a concern that significant variation between hospitals was found in the investigation and detection of physical abuse as confirmed by CPCC decisions. To minimise failure to detect true cases of physical abuse, we recommend that all high-risk children should be assessed by a paediatrician prior to discharge from the emergency department. Our proposed criteria for assessment (where we found probability of CPCC decision of physical abuse was at least 10%) are any child under the age of 12 months with any fracture, under 18 months of age with femur fracture and under 24 months with humeral shaft fracture (not supracondylar).
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Affiliation(s)
- Piers D Mitchell
- Department of Orthopaedics, Peterborough City Hospital, Peterborough, UK
| | - Richard Brown
- Department of Paediatrics, Peterborough City Hospital, Peterborough, UK
| | - Tengyao Wang
- Statistical Laboratory, University of Cambridge, Cambridge, UK
| | - Rajen D Shah
- Statistical Laboratory, University of Cambridge, Cambridge, UK
| | | | - Sue Deakin
- Department of Orthopaedics, West Suffolk Hospital, Suffolk, UK
| | - Phillip Edge
- Department of Orthopaedics, Bedford Hospital NHS Trust, Bedford, UK
| | - Ivan Hudson
- Department of Orthopaedics, Ipswich Hospital, Ipswich, UK
| | - Rachel Hutchinson
- Department of Orthopaedics, Norfolk and Norwich Hospital, Norwich, UK
| | - Kuldeep Stohr
- Department of Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Mark Latimer
- Department of Orthopaedics, Peterborough City Hospital, Peterborough, UK
| | - Rajan Natarajan
- Department of Orthopaedics, Northampton General Hospital, Northampton, UK
| | - Sultan Qasim
- Department of Orthopaedics, Bedford Hospital NHS Trust, Bedford, UK
| | - Andreas Rehm
- Department of Orthopaedics, Addenbrooke's Hospital, Cambridge, UK
| | - Anish Sanghrajka
- Department of Orthopaedics, Norfolk and Norwich Hospital, Norwich, UK
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Rosenthal B, Skrbin J, Fromkin J, Heineman E, McGinn T, Richichi R, Berger RP. Integration of physical abuse clinical decision support at 2 general emergency departments. J Am Med Inform Assoc 2019; 26:1020-1029. [PMID: 31197358 PMCID: PMC7647214 DOI: 10.1093/jamia/ocz069] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/29/2019] [Accepted: 04/26/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study sought to develop and evaluate an electronic health record-based child abuse clinical decision support system in 2 general emergency departments. MATERIALS AND METHODS A combination of a child abuse screen, natural language processing, physician orders, and discharge diagnoses were used to identify children <2 years of age with injuries suspicious for physical abuse. Providers received an alert and were referred to a physical abuse order set whenever a child triggered the system. Physician compliance with clinical guidelines was compared before and during the intervention. RESULTS A total of 242 children triggered the system, 86 during the preintervention and 156 during the intervention. The number of children identified with suspicious injuries increased 4-fold during the intervention (P < .001). Compliance was 70% (7 of 10) in the preintervention period vs 50% (22 of 44) in the intervention, a change that was not statistically different (P = .55). Fifty-two percent of providers said that receiving the alert changed their clinical decision making. There was no relationship between compliance and provider or patient demographics. CONCLUSIONS A multifaceted child abuse clinical decision support system resulted in a marked increase in the number of young children identified as having injuries suspicious for physical abuse in 2 general emergency departments. Compliance with published guidelines did not change; we hypothesize that this is related to the increased number of children identified with suspicious, but less serious injuries. These injuries were likely missed preintervention. Tracking compliance with guidelines over time will be important to assess whether compliance increases as physician comfort with evaluation of suspected physical abuse in young children improves.
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Affiliation(s)
- Bruce Rosenthal
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janet Skrbin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janet Fromkin
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Emily Heineman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tom McGinn
- Department of Medicine, Hofstra Northwell School of Medicine, Manhasset, New York, USA
| | | | - Rachel P Berger
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
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Compliance With Skeletal Surveys for Child Abuse in General Hospitals: A Statewide Quality Improvement Process. AJR Am J Roentgenol 2019; 212:976-981. [PMID: 30860887 DOI: 10.2214/ajr.18.20701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE. The purpose of this study is to perform a statewide quality improvement process to improve compliance with the American College of Radiology (ACR) guidelines in performing skeletal surveys for suspected child abuse. SUBJECTS AND METHODS. We prospectively identified all outside hospital skeletal surveys for suspected child abuse in children younger than 3 years referred to our tertiary children's hospital in 2016-2017. We included a 3-month baseline and 21-month intervention period. The quality improvement process was based on sending educational material to all ACR member radiologists in the state and making telephone calls to radiology technologist team leaders whenever the surveys were not compliant, followed by e-mails with guidance on performing skeletal surveys. We documented the views obtained and compared them with the ACR guidelines. The percentage of compliance with each individual view was assessed with the chi-square test. The total number of compliant views per survey was evaluated with ANOVA. RESULTS. Two hundred twenty-seven patients (105 female) with a mean age of 0.8 year (SD, 0.67 year; range, 0.01-3 years) were evaluated. These 227 surveys (baseline, n = 27; postintervention, n = 200) were performed at 69 different outside hospitals. Compliance significantly (p = 0.006) improved from 25.9% (7/27) during baseline to 54.0% (108/200) after intervention. There was a nonsignificant trend of improved compliance between the first (51.9%; 41/79) and last 7-month (62.3%; 33/53) periods of intervention. Among individual views, only rib oblique views showed significantly (p = 0.02) improved compliance after the intervention, from 51.9% (14/27) to 73.5% (147/200). CONCLUSION. The compliance rate with ACR guidelines for skeletal surveys in suspected child abuse at outside general hospitals significantly increased after implementation of a quality improvement process.
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The added value of a second read by pediatric radiologists for outside skeletal surveys. Pediatr Radiol 2019; 49:203-209. [PMID: 30367201 DOI: 10.1007/s00247-018-4276-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/28/2018] [Accepted: 10/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Fractures are the second most common finding in non-accidental trauma after cutaneous signs. Interpreting skeletal surveys could be challenging as some fractures are subtle and due to anatomical variations that can mimic injuries. OBJECTIVE To determine the effect of a second read by a pediatric radiologist of skeletal surveys for suspected non-accidental trauma initially read at referring hospitals by general radiologists. MATERIALS AND METHODS In 2016 and 2017, we identified all patients referred to our children's hospital with previous surveys performed and read at a community hospital by an outside radiologist. We excluded patients older than 3 years and studies performed at a children's hospital. The surveys were reviewed by a pediatric radiologist with the printed outside report available. Surveys with disagreement between outside read and pediatric radiologist read were reviewed by a second pediatric radiologist. A disagreement in the second read included only definite discrepant findings agreed upon by both pediatric radiologists. The Fisher exact test was performed to compare the ratio of discrepancies between readers in normal and abnormal surveys. RESULTS Two hundred twenty-five surveys were performed (120 male) at 62 referring hospitals, with a mean patient age of 10.5 months (range: 5 days-3 years). The outside read identified fractures in 104/225 (46.2%) surveys. Thirty-seven of the 225 (16.4%) contained discrepancies in interpretation (n=111). Most of these disagreements (29/37, 78.4%) resulted in a significant change in the report. There was a significant (P<0.0001) difference between disagreement rate in outside read negative (4/111, 3.2%) and positive surveys (34/104, 31.7%). The second read identified additional fractures in 22/225 (9.8%) of the surveys and disagreed with first-read fractures in 17/256 (7.6%). Four of 19 (21.1%) classic metaphyseal lesions diagnosed by the outside read were normal variants; 18 classic metaphyseal lesions were missed by the outside read. CONCLUSIONS This study supports second reads by pediatric radiologists of skeletal surveys for non-accidental trauma.
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18
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Early Recognition of Physical Abuse: Bridging the Gap between Knowledge and Practice. J Pediatr 2019; 204:16-23. [PMID: 30268403 DOI: 10.1016/j.jpeds.2018.07.081] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/25/2018] [Accepted: 07/25/2018] [Indexed: 11/22/2022]
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Wood JN, Henry MK, Berger RP, Lindberg DM, Anderst JD, Song L, Localio R, Feudtner C. Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in Young Injured Children. Acad Pediatr 2019; 19:428-437. [PMID: 30121318 PMCID: PMC6377846 DOI: 10.1016/j.acap.2018.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/06/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To describe the percentage and characteristics of children aged <24 months with non-motor vehicle crash (MVC)-related injuries who undergo a skeletal survey and have occult fractures. METHODS We performed a retrospective chart review of a stratified, systematic random sample of 1769 children aged<24 months with non-MVC-related bruises, burns, fractures, abdominal injuries, and head injuries at 4 children's hospitals between 2008 and 2012. Sampling weights were assigned to each child to allow for representative hospital-level population estimates. Logistic regression models were used to test for associations between patient characteristics with outcomes of skeletal survey completion and occult fracture identification. RESULTS Skeletal surveys were performed in 46.3% of children aged 0 to 5 months, in 21.1% of those aged 6 to 11 months, in 8.0% of those aged 12 to 17 months, and in 6.2% of those aged 18 to 24 months. Skeletal surveys were performed most frequently in children with traumatic brain injuries (64.7%) and rib fractures (100%) and least frequently in those with burns (2.1%) and minor head injuries (4.4%). In adjusted analyses, older age, private insurance, and reported history of accidental trauma were associated with decreased skeletal survey use (P ≤ .001 for all). The prevalence of occult fractures on skeletal surveys ranged from 24.6% in children aged 0 to 5months to 3.6% in those aged 18 to 24 months, and varied within age categories based on the presenting injury (P < .001). CONCLUSIONS The high rate of occult fractures in infants aged 0 to 5 months underscores the importance of increasing the use of skeletal surveys in this population. Further research is needed to identify the injury characteristics of older infants and toddlers most at risk for occult fractures.
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Affiliation(s)
- Joanne N Wood
- Center for Pediatric Clinical Effectiveness (JN Wood, MK Henry, L, Song, and C Feudtner); PolicyLab (JN Wood and L Song), Division of General Pediatrics, Roberts Center for Pediatric Research, Children's Hospital of Philadelphia; Department of Pediatrics (JN Wood, MK Henry, and C Feudtner), Perelman School of Medicine at the University of Pennsylvania.
| | - M. Katherine Henry
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Division of General Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA 19146,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104
| | - Rachel P. Berger
- Department of Pediatrics, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Safar Center for Resuscitation Research, University of Pittsburgh, 4401 Penn Ave, 2nd Floor, Pittsburgh, PA 15224
| | - Daniel M. Lindberg
- Department of Emergency Medicine and The Kempe Center for the Prevention and Treatment of Child Abuse & Neglect. University of Colorado School of Medicine. 12401 E. 17th Ave. Aurora, CO 80238
| | - James D. Anderst
- Department of Pediatrics, Division of Child Abuse and Neglect, University of Missouri Kansas City School of Medicine and Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 6410
| | - Lihai Song
- PolicyLab, Children’s Hospital of Philadelphia, Division of General Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA 19146
| | - Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 204 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104
| | - Chris Feudtner
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Division of General Pediatrics, Children’s Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South Street, Philadelphia, PA 19146,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104
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20
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Boehnke M, Mirsky D, Stence N, Stanley RM, Lindberg DM. Occult head injury is common in children with concern for physical abuse. Pediatr Radiol 2018; 48:1123-1129. [PMID: 29654352 DOI: 10.1007/s00247-018-4128-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/08/2018] [Accepted: 03/25/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. OBJECTIVES Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. MATERIALS AND METHODS This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. RESULTS One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. CONCLUSION Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.
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Affiliation(s)
- Mitchell Boehnke
- Department of Diagnostic Radiology, Children's Hospital Colorado, 12631 East 17th Ave., Mail Stop 8200, Aurora, CO, 80045, USA. .,University of Colorado School of Medicine, Aurora, CO, USA.
| | - David Mirsky
- Department of Diagnostic Radiology, Children's Hospital Colorado, 12631 East 17th Ave., Mail Stop 8200, Aurora, CO, 80045, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicholas Stence
- Department of Diagnostic Radiology, Children's Hospital Colorado, 12631 East 17th Ave., Mail Stop 8200, Aurora, CO, 80045, USA.,University of Colorado School of Medicine, Aurora, CO, USA
| | - Rachel M Stanley
- Department of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University School of Medicine, Columbus, OH, USA
| | - Daniel M Lindberg
- University of Colorado School of Medicine, Aurora, CO, USA.,The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, Aurora, CO, USA
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21
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Gan T, Draus JM. Improving Follow-up Skeletal Survey Compliance in Suspected Nonaccidental Trauma Patients: What's the FUSS About? Pediatr Qual Saf 2018; 3:e094. [PMID: 30229204 PMCID: PMC6135555 DOI: 10.1097/pq9.0000000000000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 06/22/2018] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Nonaccidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. The skeletal survey (SS) and follow-up skeletal survey (FUSS) are essential in the evaluation of selected NAT patients. We identified that our clinically indicated FUSS completion rate was suboptimal. We hypothesized that implementing an intervention of postdischarge follow-up in our pediatric surgery clinic would improve FUSS completion rates. METHODS A follow-up clinic for NAT patients was established in July 2013. A retrospective review was performed of all suspected NAT cases younger than 2 years old seen at Kentucky Children's Hospital between November 2012 and February 2014. The study population was divided into pre (Group 1) and postintervention (Group 2). Bivariate analysis was performed. RESULTS Group 1 consisted of 50 patients (58% male; median age, 9 months). Forty-7 (94%) had an SS; fractures were identified in 37 (74%) patients. Only 20 patients (40%) had FUSS; of those, 4 had newly identified fractures. Group 2 consisted of 52 patients (54% male; median age, 7 months). All 52 children (100%) had an SS; fractures were identified in 35 (67%) patients. Forty-seven patients (90%) had FUSS. Of those, 6 had new radiographic findings. Thirty-five patients (67%) were seen in our clinic. This improvement in FUSS (40% versus 90%) was statistically significant, P < 0.001. CONCLUSION The decision to follow NAT patients in our clinic had significantly increased our rates of FUSS completion. This additional clinic follow-up also provided more evidence for NAT evaluation.
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Affiliation(s)
- Tong Gan
- From the Department of Surgery, Division of Pediatric Surgery, Kentucky Children’s Hospital, University of Kentucky, Lexington, Ky
| | - John M. Draus
- From the Department of Surgery, Division of Pediatric Surgery, Kentucky Children’s Hospital, University of Kentucky, Lexington, Ky
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22
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Flannery DD, Ross RK, Mukhopadhyay S, Tribble AC, Puopolo KM, Gerber JS. Temporal Trends and Center Variation in Early Antibiotic Use Among Premature Infants. JAMA Netw Open 2018; 1:e180164. [PMID: 30646054 PMCID: PMC6324528 DOI: 10.1001/jamanetworkopen.2018.0164] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Premature infants are frequently administered empirical antibiotic therapy at birth. Early and prolonged antibiotic exposures among infants without culture-confirmed infection have been associated with increased risk of adverse outcomes. OBJECTIVE To examine early antibiotic use among premature infants over time and across hospitals in the United States. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used a comprehensive administrative database of inpatient encounters from 297 academic and community hospitals across the United States to examine data concerning very low-birth-weight (VLBW) infants (<1500 g), including extremely low-birth-weight (ELBW) infants (<1000 g), who were admitted to the neonatal intensive care unit and survived for at least 1 day. Data collection took place in November 2015 and analysis took place from February 2016 to November 2016. EXPOSURES Antibiotic initiation within the first 3 days of age and subsequent antibiotic administration for more than 5 days. MAIN OUTCOMES AND MEASURES Temporal trends in early antibiotic initiation and duration from 2009 to 2015, and center variation in early antibiotic use from 2014 to 2015. RESULTS We identified 40 364 VLBW infants (20 447 female [50.7%]) who survived for at least 1 day, including 12 947 ELBW infants, from 297 centers. The majority of premature infants had early antibiotic initiation (31 715 VLBW infants [78.6%] and 11 264 ELBW infants [87.0%]), and no differences were observed over time in temporal trend analyses (P = .12 for VLBW and P = .52 for ELBW). The annual risk difference in the proportion of VLBW infants administered early antibiotic therapy ranged from -0.75% (95% CI, -1.61% to 0.11%) to -0.87% (95% CI, -2.04% to 0.30%); in ELBW infants the annual risk difference ranged from -0.34% (95% CI, -1.28% to 0.61%) to -0.38% (95% CI, -1.61% to 0.85%). There was a small but significant decrease over time in the rate of prolonged antibiotic duration for VLBW infants (P = .02), but not for ELBW infants (P = .22). The annual risk difference in the proportion of VLBW infants with prolonged antibiotic duration ranged from -0.94% (95% CI, -1.65% to -0.23%) to -1.08% (95% CI, -2.00% to -0.16%); in ELBW infants the annual risk difference ranged from -0.72% (95% CI, -1.83% to 0.39%) to -0.75% (95% CI, -1.96% to 0.46%). We also observed variation in early antibiotic exposures across centers. Sixty-nine of 113 centers (61.1%) started antibiotic therapy for more than 75% of VLBW infants, and 56 of 66 centers (84.8%) started antibiotic therapy for more than 75% of ELBW infants. The proportion of VLBW and ELBW infants administered prolonged antibiotics ranged from 0% to 80.4% and 0% to 92.0% across centers, respectively. CONCLUSIONS AND RELEVANCE Most premature infants in this study received empirical early antibiotic therapy with little change over a recent 7-year period. The variability in exposure rates across centers, however, suggests that neonatal antimicrobial stewardship efforts are warranted to optimize antibiotic use for VLBW and ELBW infants.
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Affiliation(s)
- Dustin D Flannery
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Rachael K Ross
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Pediatric Infectious Diseases, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Sagori Mukhopadhyay
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Alison C Tribble
- Division of Pediatric Infectious Diseases, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | - Karen M Puopolo
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Jeffrey S Gerber
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Pediatric Infectious Diseases, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
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23
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Paine CW, Wood JN. Skeletal surveys in young, injured children: A systematic review. CHILD ABUSE & NEGLECT 2018; 76:237-249. [PMID: 29154020 PMCID: PMC5771942 DOI: 10.1016/j.chiabu.2017.11.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 11/04/2017] [Accepted: 11/08/2017] [Indexed: 06/07/2023]
Abstract
Skeletal surveys (SSs) have been identified as a key component of the evaluation for suspected abuse in young children, but variability in SS utilization has been reported. Thus, we aimed to describe the utilization patterns, yield, and risks of obtaining SS in young children through a systematic literature review. We searched PubMed/MEDLINE and CINAHL databases for articles published between 1990 and 2016 on SS. We calculated study-specific percentages of SS utilization and detection of occult fractures and examined the likelihoods that patient characteristics predict SS utilization and detection of occult fractures. Data from 32 articles represents 64,983 children <60months old. SS utilization was high (85%-100%) in studies of infants evaluated by a child protection team for suspected abuse and/or diagnosed with abuse except in one study of primarily non-pediatric hospitals. Greater variability in SS utilization was observed across studies that included all infants with specific injuries, such as femur fractures (0%-77%), significant head injury (51%-82%), and skull fractures (41%-86%). Minority children and children without private insurance were evaluated with SS more often than white children and children with private insurance despite lack of evidence to support this practice. Among children undergoing SS, occult fractures were frequently detected among infants with significant head injury (23%-34%) and long bone fractures (30%) but were less common in infants with skull fractures (1%-6%). These findings underscore the need for interventions to decrease disparities in SS utilization and standardize SS utilization in infants at high risk of having occult fractures.
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Affiliation(s)
- Christine W Paine
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, 10th floor, Philadelphia, PA, 19146, USA.
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; PolicyLab, Children's Hospital of Philadelphia, 2716 South Street, 10th floor, Philadelphia, PA, 19146, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, USA.
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Kim PT, McCagg J, Dundon A, Ziesler Z, Moody S, Falcone RA. Consistent screening of admitted infants with head injuries reveals high rate of nonaccidental trauma. J Pediatr Surg 2017; 52:1827-1830. [PMID: 28302360 DOI: 10.1016/j.jpedsurg.2017.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/23/2017] [Accepted: 02/22/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Implementation of a nonaccidental trauma (NAT) screening guideline for the evaluation of infants admitted with an unwitnessed head injury has eliminated screening disparities. This study sought to determine the overall NAT rate and key predictive factors using this guideline. METHODS All infants screened via the guideline from 2008 to 2015 were retrospectively reviewed. The overall rate of NAT as determined by our child abuse team was determined. In addition, a logistic regression model was developed to evaluate potential predictors of increased risk of NAT. RESULTS A total of 563 infants were screened with an overall rate of NAT of 25.6% (n=144). NAT screening was consistent across race and insurance status. By univariate analysis, patients with government insurance or no insurance had a significantly higher rate of NAT, but race was not a factor. Also NAT victims had significantly higher ISS. Skeletal survey showed high positive predictive value of 94%. When regression modeling was performed, ISS, abnormal skeletal survey and having public or no insurance were significantly correlated with NAT, while race showed no correlation. CONCLUSION One quarter of infants admitted with a head injury not witnessed in a public situation were identified as the victims of NAT. The high rate of abuse among this population supports routine screening in order to avoid missing intentional injuries and preventing future injuries. Race is not a predictor of NAT, but insurance status, as a proxy for socioeconomic status, is correlated, and further investigation is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Paul T Kim
- Trauma Service, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH
| | - Jillian McCagg
- Marshal University, 1 John Marshall Dr., Huntington, WV 25755
| | - Ashley Dundon
- Trauma Service, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH
| | - Zach Ziesler
- Trauma Service, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH
| | - Suzanne Moody
- Trauma Service, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH
| | - Richard A Falcone
- Trauma Service, Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2023, Cincinnati, OH.
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Wheeler KK, Shi J, Xiang H, Haley KJ, Groner JI. Child maltreatment in U.S. emergency departments: Imaging and admissions. CHILD ABUSE & NEGLECT 2017; 69:96-105. [PMID: 28456069 DOI: 10.1016/j.chiabu.2017.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 02/20/2017] [Accepted: 04/14/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We report imaging and admission ratios for children with definitive and suggestive maltreatment in a national sample of emergency departments (EDs). METHODS Using the 2012 Nationwide Emergency Department Sample (NEDS), we generated national estimates of ED visits for children <10 years with both definitive and suggestive maltreatment. Outcomes were admission/transfer ratios for children <10years and screening ratios by skeletal surveys and head computed tomography (CT) for children <2 years with suspected physical abuse. We compared hospitals with low, medium, and high pediatric ED volumes using multivariable logistic regression. RESULTS The 2012 national estimate of U.S. ED visits (children <10years) with definitive maltreatment is 14,457 (95% CI: 11,987-16,928). Suggestive child maltreatment was seen in an additional 103,392 (95% CI: 90,803-115,981) pediatric ED visits. After controlling for patient case mix, high volume hospitals had a significantly higher adjusted odds ratio (AOR) of admission/transfer among definitive cases (AOR=1.74, 95% CI: 1.08-2.81), and medium volume hospitals had a higher odds of admission/transfer among suggestive cases (AOR=1.24, 95% CI: 1.02-1.50) when compared with low volume hospitals. In hospitals with reliable reporting of imaging procedures, high volume hospitals reported skeletal surveys (age <2 years) significantly more often than low volume hospitals, AOR=3.32 (95% CI: 1.25-8.84); the AORs for head CT did not differ by hospital volume. CONCLUSIONS Low volume hospitals were less likely to screen by skeletal survey, but head CT ratios were not affected by ED volume. Low volume hospitals were also less likely to admit or transfer.
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Affiliation(s)
- Krista K Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Henry Xiang
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH, USA
| | - Kathy J Haley
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Trauma Program, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jonathan I Groner
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; The Ohio State University College of Medicine, 370 West 9th Avenue, Columbus, OH, USA; Trauma Program, Nationwide Children's Hospital, Columbus, OH, USA.
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Lindberg DM, Wood JN, Campbell KA, Scribano PV, Laskey A, Leventhal JM, Pierce MC, Runyan DK. Research priorities for a multi-center child abuse pediatrics network - CAPNET. CHILD ABUSE & NEGLECT 2017; 65:152-157. [PMID: 28161656 PMCID: PMC5774239 DOI: 10.1016/j.chiabu.2017.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 01/21/2017] [Indexed: 05/30/2023]
Abstract
Although child maltreatment medical research has benefited from several multi-center studies, the new specialty of child abuse pediatrics has not had a sustainable network capable of pursuing multiple, prospective, clinically-oriented studies. The Child Abuse Pediatrics Network (CAPNET) is a new multi-center research network dedicated to child maltreatment medical research. In order to establish a relevant, practical research agenda, we conducted a modified Delphi process to determine the topic areas with highest priority for such a network. Research questions were solicited from members of the Ray E. Helfer Society and study authors and were sorted into topic areas. These topic areas were rated for priority using iterative rounds of ratings and in-person meetings. The topics rated with the highest priority were missed diagnosis and selected/indicated prevention. This agenda can be used to target future multi-center child maltreatment medical research.
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Affiliation(s)
- Daniel M Lindberg
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, United States.
| | - Joanne N Wood
- Division of General Pediatrics and PolicyLab, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Safe Place: Center for Child Protection and Health, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Kristine A Campbell
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States.
| | - Philip V Scribano
- Safe Place: Center for Child Protection and Health, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States.
| | - Antoinette Laskey
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States.
| | - John M Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, United States.
| | - Mary Clyde Pierce
- Department of Pediatrics, Feinberg School of Medicine Northwestern University, United States.
| | - Desmond K Runyan
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, United States.
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Henry MK, Wood JN, Metzger KB, Kim KH, Feudtner C, Zonfrillo MR. Relationship between Insurance Type and Discharge Disposition From the Emergency Department of Young Children Diagnosed with Physical Abuse. J Pediatr 2016; 177:302-307.e1. [PMID: 27423175 PMCID: PMC5526595 DOI: 10.1016/j.jpeds.2016.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/20/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the disposition of young children diagnosed with physical abuse in the emergency department (ED) setting and identify factors associated with the decision to discharge young abused children. STUDY DESIGN We performed a retrospective cross-sectional study of children less than 2 years of age diagnosed with physical abuse in the 2006-2012 Nationwide Emergency Department Sample. National estimates were calculated accounting for the complex survey design. We developed a multivariable logistic regression model to evaluate the relationship between payer type and discharge from the ED compared with admission with adjustment for patient and hospital factors. RESULTS Of the 37 655 ED encounters with a diagnosis of physical abuse among children less than 2 years of age, 51.8% resulted in discharge, 41.2% in admission, 4.3% in transfer, 0.3% in death in the ED, and 2.5% in other. After adjustment for age, sex, injury type, and hospital characteristics (trauma designation, volume of young children, and hospital region), there were differences in discharge decisions by payer and injury severity. The adjusted percentage discharged of publicly insured children with minor/moderate injury severity was 56.2% (95% CI 51.6, 60.7). The adjusted percentages discharged were higher for both privately insured children at 69.9% (95% CI 64.4, 75.5) and self-pay children at 72.9% (95% CI 67.4, 78.4). The adjusted percentages discharged among severely injured children did not differ significantly by payer. CONCLUSIONS The majority of ED visits for young children diagnosed with abuse resulted in discharge. The notable differences in disposition by payer warrant further investigation.
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Affiliation(s)
- M Katherine Henry
- Center for Pediatric Clinical Effectiveness; Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Joanne N Wood
- Center for Pediatric Clinical Effectiveness; Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; PolicyLab
| | - Kristina B Metzger
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Konny H Kim
- Health Coverage for Low-Income and Uninsured Populations, RTI International, Washington, DC
| | - Chris Feudtner
- Center for Pediatric Clinical Effectiveness; Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mark R Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
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Abstract
PURPOSE OF REVIEW This review addresses some of the more salient articles in the field of child maltreatment published in 2015, with a goal of helping the general practitioner understand the evolution of research in the field of child abuse pediatrics (a board-certified specialty since 2009). RECENT FINDINGS Researchers continue to refine the database for child abuse pediatrics. Several articles focus on the inconsistencies in approach to the evaluation of possible physical child abuse between hospitals and practitioners. Multiple researchers aim to develop a protocol that standardizes the response to findings of a sentinel injury, such as a rib fracture, abdominal trauma, or unexplained bruising in a nonambulatory infant. Professionals are also working to improve our understanding about the impact of trauma on children and how best to ameliorate its effects. SUMMARY With solid, evidence-based literature published on various topics in the field of child abuse pediatrics, experts work to refine and unify the clinician's approach to the evaluation of possible physical abuse.
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[Accident or maltreatment? Radiographic X‑ray patterns in non‑accidental trauma : The concept of sentinel injuries]. Radiologe 2016; 56:414-23. [PMID: 27118367 DOI: 10.1007/s00117-016-0102-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The focus of this review article is on child abuse and the radiographic pattern of X‑ray findings. The radiologist should be able to recognize typical injuries resulting from child abuse. In some cases the findings are highly specific for abuse and these include metaphyseal corner fractures of the long bones in children aged up to 24 months. In other cases the fractures are not specific but highly indicative of child abuse: rib fractures, for example can be associated with child abuse in more than 50 % of the cases; however, maltreatment is difficult to diagnose without taking the entire pattern of skeletal findings into consideration so that a radiological screening of the entire skeleton is often necessary. The concept of sentinel injuries might be helpful for deciding in which cases a complete skeletal screening should be performed. In the age group up to 24 months old a complete skeletal status (with some exceptions) is recommended if one of the three sentinel injuries of rib fractures, intracranial bleeding and abdominal trauma is present.
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Paine CW, Scribano PV, Localio R, Wood JN. Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage. Pediatrics 2016; 137:peds.2015-3024. [PMID: 26956102 PMCID: PMC4811312 DOI: 10.1542/peds.2015-3024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE As evidenced by the variation and disparities in evaluation, there is uncertainty in determining which young children with intracranial hemorrhage (ICH) should undergo evaluation with skeletal survey (SS) for additional injuries concerning for abuse. We aimed to develop guidelines for performing initial SS in children <24 months old presenting with ICH by combining available evidence from the literature with expert opinion. METHODS Using the RAND/UCLA Appropriateness Method, a multispecialty panel of 12 experts used the literature and their own clinical expertise to rate the appropriateness of performing SS for 216 scenarios characterizing children <24 months old with ICH. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 74 revised scenarios. For the 63 scenarios in which SS was deemed appropriate, the panel rated the necessity of SS. RESULTS Panelists concluded that SS is appropriate for 85% (63), uncertain for 15% (11), and inappropriate for 0% of scenarios. Panelists determined that SS is necessary in all scenarios deemed appropriate. SS was deemed necessary for infants <6 months old and for children <24 months old with subdural hemorrhage that is not tiny and under a skull fracture. For children 6 to 23 months old with epidural hemorrhage, necessity of SS depended on the child's age, history of trauma, signs/symptoms, and ICH characteristics. CONCLUSIONS The resulting clinical guidelines call for near-universal evaluation in children <24 months old presenting with ICH. Detailed, validated guidelines that are successfully implemented may decrease variation and disparities in care.
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Affiliation(s)
- Christine Weirich Paine
- Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | - Russell Localio
- Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joanne N. Wood
- Division of General Pediatrics and,PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and,Departments of Pediatrics and
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Hoytema van Konijnenburg EMM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR. Paediatric femur fractures at the emergency department: accidental or not? Br J Radiol 2015; 89:20150822. [PMID: 26642309 DOI: 10.1259/bjr.20150822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Only a small proportion of all paediatric fractures is caused by child abuse or neglect, especially in highly prevalent long bone fractures. It can be difficult to differentiate abusive fractures from non-abusive fractures. This article focuses on femoral fractures in young children. Based on three cases, this article presents a forensic evidence-based approach to differentiate between accidental and non-accidental causes of femoral fractures. We describe three cases of young children who were presented to the emergency department because of a suspected femur fracture. Although in all cases, the fracture had a similar location and appearance, the clinical history and developmental stage of the child led to three different conclusions. In the first two cases, an accidental mechanism was a plausible conclusion, although in the second case, neglect of parental supervision was the cause for concern. In the third case, a non-accidental injury was diagnosed and appropriate legal prosecution followed. Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and non-mobile children presenting with an unknown trauma mechanism. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. In order to make a good assessment, the radiologist reviewing the skeletal survey needs access to all relevant clinical and social information.
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Affiliation(s)
| | | | - Roel Bakx
- 2 Pediatric Surgical Center Amsterdam, Emma Children's Hospital, Academic Medical Center and VU University Medical Center, Amsterdam, Netherlands
| | - Rick R Van Rijn
- 3 Department of Radiology, Emma Children's Hospital, Academic Medical Center, Amsterdam, Netherlands
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Campbell KA. Outcome Data Needed: Interpreting Variation in the Medical Evaluation of Child Physical Abuse. Pediatrics 2015; 136:389-91. [PMID: 26169423 PMCID: PMC9923576 DOI: 10.1542/peds.2015-0694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kristine A. Campbell
- Address correspondence to Kristine A. Campbell, MD, MSc, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO Box 581289, Salt Lake City, UT 84158. E-mail:
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