Search

Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine if children identified by a predictive risk model as at "high risk" of maltreatment are also at elevated risk of injury and mortality in early childhood. METHODS: We built a model that predicted a child's risk of a substantiated finding of maltreatment by child protective services for children born in New Zealand in 2010. We assigned risk scores to the 2011 birth cohort, and flagged children as "very high risk" if they were in the top 10% of the score distribution for maltreatment. We also set a less conservative threshold for defining "high risk" and examined children in the top 20%. We then compared the incidence of injury and mortality rates between very high-risk and high-risk children and the remainder of the birth cohort. RESULTS: Children flagged at both 10% and 20% risk thresholds had much higher postneonatal mortality rates than other children (4.8 times and 4.2 times greater, respectively), as well as a greater relative risk of hospitalization (2 times higher and 1.8 times higher, respectively). CONCLUSIONS: Models that predict risk of maltreatment as defined by child protective services substantiation also identify children who are at heightened risk of injury and mortality outcomes. If deployed at birth, these models could help medical providers identify children in families who would benefit from more intensive supports. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVE: Child maltreatment remains a problem in the United States, and individual poverty is a recognized risk factor for abuse. Children in impoverished communities are at risk for negative health outcomes, but the relationship of community poverty to child abuse fatalities is not known. Our objective was to evaluate the association between county poverty concentration and rates of fatal child abuse. METHODS: This was a retrospective, cross-sectional analysis of child abuse fatalities in US children 0 to 4 years of age from 1999 to 2014 by using the Centers for Disease Control and Prevention Compressed Mortality Files. Population and poverty statistics were obtained from US Census data. National child abuse fatality rates were calculated for each category of community poverty concentration. Multivariate negative binomial regression modeling assessed the relationship between county poverty concentration and child abuse fatalities. RESULTS: From 1999 to 2014, 11149 children 0 to 4 years old died of child abuse; 45% (5053) were <1 year old, 56% (6283) were boys, and 58% (6480) were white. The overall rate of fatal child abuse was 3.5 per 100 000 children 0 to 4 years old. In the multivariate model, counties with the highest poverty concentration had >3 times the rate of child abuse fatalities compared with counties with the lowest poverty concentration (adjusted incidence rate ratio, 3.03; 95% confidence interval, 2.4-3.79). CONCLUSIONS: Higher county poverty concentration is associated with increased rates of child abuse fatalities. This finding should inform public health officials in targeting high-risk areas for interventions and resources. [ABSTRACT FROM AUTHOR]

The last decade has witnessed major reductions in child mortality and a focus on saving lives with key interventions targeting major causes of child deaths, such as neonatal deaths and those due to childhood diarrhea and pneumonia. With the transition to Sustainable Development Goals, the global health community is expanding child health initiatives to address not only the ongoing need for reduced mortality, but also to decrease morbidity and adverse exposures toward improving health and developmental outcomes. The relationship between adverse environmental exposures frequently associated with factors operating in the prepregnancy period and during fetal development is well established. Also well appreciated are the developmental impacts (both short- and long-term) associated with postnatal factors, such as immunostimulation and environmental enteropathy, and the additional risks posed by the confluence of factors related to malnutrition, poor living conditions, and the high burden of infections. This article provides our current thinking on the pathogenesis and risk factors for adverse developmental outcomes among young children, setting the scene for potential interventions that can ameliorate these adversities among families and children at risk. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the relation between county-level income inequality and rates of child maltreatment. METHODS: Data on substantiated reports of child abuse and neglect from 2005 to 2009 were obtained from the National Child Abuse and Neglect Data System. County-level data on income inequality and children in poverty were obtained from the American Community Survey. Data for additional control variables were obtained from the American Community Survey and the Health Resources and Services Administration Area Resource File. The Gini coefficient was used as the measure of income inequality. Generalized additive models were estimated to explore linear and nonlinear relations among income inequality, poverty, and child maltreatment. In all models, state was included as a fixed effect to control for state- level differences in victim rates. RESULTS: Considerable variation in income inequality and child maltreatment rates was found across the 3142 US counties. Income inequality, as well as child poverty rate, was positively and significantly correlated with child maltreatment rates at the county level. Controlling for child poverty, demographic and economic control variables, and state-level variation in maltreatment rates, there was a significant linear effect of inequality on child maltreatment rates (P < .0001). This effect was stronger for counties with moderate to high levels of child poverty. CONCLUSIONS: Higher income inequality across US counties was significantly associated with higher county-level rates of child maltreatment. The findings contribute to the growing literature linking greater income inequality to a range of poor health and well-being outcomes in infants and children. Pediatrics 2014; 133:454-461 [ABSTRACT FROM AUTHOR]

OBJECTIVE: Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. PATIENTS AND METHODS: This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. RESULTS: Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54(3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 lU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. CONCLUSIONS: In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 lU/L or with abdominal bruising, distention, or tenderness. [ABSTRACT FROM AUTHOR]

OBJECTIVE. Inflicted traumatic brain injury (iTBI) is the leading cause of death from TBI in infants. Misdiagnosis of iTBI is common and results in increased morbidity and mortality. Biomarkers may be able to assist in screening infants who are at high risk for iTBI and whose injury might otherwise be missed. We investigated whether serum and/or cerebrospinal fluid (CSF) concentrations of neuron-specific enolase (NSE), S100B, and myelin-basic protein (MBP) are sensitive and specific for iTBI in high-risk infants. METHODS. A prospective case-control study was conducted of 98 well-appearing infants who presented with nonspecific symptoms and no history of trauma. Serum or CSF was collected. NSE, S100B, and MBP concentrations were measured by enzyme-linked immunosorbent assay. Abnormal marker concentrations were defined a priori. Patients were followed for 12 months to assess for subsequent abuse. RESULTS. Fourteen patients received a clinical diagnosis of iTBI. Using preestablished cutoffs, NSE was 77% sensitive and 66% specific and MBP was 36% sensitive and 100% specific for iTBI. S100B was neither sensitive nor specific for iTBI. Five patients who were not identified with iTBI at enrollment were identified at follow-up as being possible victims of abuse; 4 had an increased NSE concentration at enrollment. CONCLUSIONS. Serum and/or CSF concentrations of NSE and MBP may be useful as a screening test to identify infants who are at increased risk for iTBI and may benefit from additional evaluation with a head computed tomography scan. S100B is neither sensitive nor specific for iTBI in this study population. The ability to identify iTBI that might otherwise be missed has important implications for decreasing the morbidity and the mortality from iTBI. [ABSTRACT FROM AUTHOR]

ABSTRACT. Objective. Head injury is the leading cause of death in abused children under 2 years of age. Evidence for establishing guidelines regarding screening for occult head injury in a neurologically asymptomatic child with other evidence of abuse is lacking. This is particularly important given that many children with acute inflicted head injury have evidence of old injury when they are diagnosed. The primary aim of this study was to estimate the prevalence of occult head injury in a high-risk sample of abused children with normal neurologic examinations. The secondary aim was to describe characteristics of this population. Methods. Children under 2 years of age admitted to an urban children's hospital between January 1998 and December 2001 with injuries suspicious for child abuse were eligible for this study if they had a normal neurologic examination on admission. Subjects were selected if they met 1 of the following "high-risk" criteria: rib fractures, multiple fractures, facial injury, or age <6 months. Subjects were excluded if they had a history of neurologic dysfunction, seizures, respiratory arrest, or if their initial physical examination revealed scalp injury. Results. Of the 65 patients who met these criteria, 51 (78.5%) had a head computed tomography or magnetic resonance imaging in addition to skeletal survey. Of these 51 patients, 19 (37.3%, 95% confidence interval 24.2-50.4%) had an occult head injury. Injuries included scalp swelling (74%), skull fracture (74%), and intracranial injury (53%). All except 3 of the head-injured patients had at least a skull fracture or intracranial injury. Skeletal survey alone missed 26% (5/19) of the cases. Head-injured children were younger than non-head-injured children (median age 2.5 vs 5.1 months); all but 1 head-injured child was <1 year of age. Among the head-injured children, 72% came from single parent households, 37% had mothers whose age was <21 years, and 26% had a history of prior child... [ABSTRACT FROM AUTHOR]

Abstract. Drowning as a form of subtle fatal child abuse is difficult to distinguish from accidental immersion or from sudden unexpected natural death when the circumstances of immersion are concealed. Homicidal drownings are unwitnessed, usually occurring in the home, and the victims are young, either infants or toddlers. Accidental drownings are more likely to involve toddlers or older children in public areas such as swimming pools, drainage ditches, lakes, and rivers. This is especially true in rural areas. In cities, bathtubs remain a major site of accidental childhood drownings. Perpetrators of deliberate drownings often fit the sociopathologie profile of a child abuser. Because there is often a survival interval between immersion and death, pathologic findings consistent with postimmersion syndrome suggest the cause of death. Foreign material in the lungs, if immersion was other than in clear tap water, and injuries of the face are other positive correlating factors. A thorough investigation of the circumstances and cooperation between the investigating agency and the pathologist are essential to determine the correct manner of death in these cases. [ABSTRACT FROM AUTHOR]

The article looks at a study that focuses on the strong predictive utility of predictive risk modeling (PRM) relative to child maltreatment and health. Topics mentioned include breakthrough represented by PRM in forecasting negative child outcomes, lack of clarity about the role of child protective services, and a decision to offer voluntary preventive services to the 10 percent of highest-risk children or the top 20 percent.

The article offers information on several articles related to pediatrics including "Addressing Childhood Obesity Requires Dedicated Clinic Time," by E. R. Roumm, "Considering Child Abuse From Another Angle," by J. Scheller, and "Reducing Preventable Child Mortality at School," by M. D. Bergren, which can be commented by sending a letter to the editor through the Submit a Response button.