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Objectives: The study objective was to determine if maternal and paternal exposure to adverse childhood experiences (ACEs) have a significant association with negative offspring development at 24 months of age in a suburban pediatric primary care population., Methods: A retrospective cohort study was conducted of 311 mother-child and 122 father-child dyads who attended a large pediatric primary care practice. Children were born from October 2012 to June 2014, and data were collected at the 2-, 4-, and 24-month well-child visits. Multivariable Poisson regression with robust error variance was used to model the relationship between self-reported parental ACEs and the outcomes of suspected developmental delay at 24 months and eligibility for early intervention services., Results: For each additional maternal ACE, there was an 18% increase in the risk for a suspected developmental delay (relative risk: 1.18, 95% confidence interval: 1.08-1.29). A similar trend was observed for paternal ACEs (relative risk: 1.34, 95% confidence interval: 1.07-1.67). Three or more maternal ACEs (versus <3 ACEs) was associated with a significantly increased risk for a suspected developmental delay that affected multiple domains. Similar effects were observed for early intervention services., Conclusions: Parental ACE exposures can negatively impact child development in multiple domains, including problem solving, communication, personal-social, and motor skills. Research is needed to elucidate the psychosocial and biological mechanisms of intergenerational risk. This research has implications for the value of parental ACE screening in the context of pediatric primary care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Objective: Routine testing of hepatic transaminases, amylase, and lipase has been recommended for all children evaluated for physical abuse, but rates of screening are widely variable, even among abuse specialists, and data for amylase and lipase testing are lacking. A previous study of screening in centers that endorsed routine transaminase screening suggested that using a transaminase threshold of 80 IU/L could improve injury detection. Our objectives were to prospectively validate the test characteristics of the 80-IU/L threshold and to determine the utility of amylase and lipase to detect occult abdominal injury., Methods: This was a retrospective secondary analysis of the Examining Siblings To Recognize Abuse research network, a multicenter study in children younger than 10 years old who underwent subspecialty evaluation for physical abuse. We determined rates of identified abdominal injuries and results of transaminase, amylase, and lipase testing. Screening studies were compared by using basic test characteristics (sensitivity, specificity) and the area under the receiver operating characteristic curve., Results: Abdominal injuries were identified in 82 of 2890 subjects (2.8%; 95% confidence interval: 2.3%-3.5%). Hepatic transaminases were obtained in 1538 (53%) subjects. Hepatic transaminases had an area under the receiver operating characteristic curve of 0.87. A threshold of 80 IU/L yielded sensitivity of 83.8% and specificity of 83.1%. The areas under the curve for amylase and lipase were 0.67 and 0.72, respectively., Conclusions: Children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury.

Objective: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children., Methods: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old., Results: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9)., Conclusions: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts.

Objective: Rib fractures are uncommon in infancy and, when diagnosed, often raise the suspicion of child abuse. However, the prevalence of other causes of rib fractures has not been well defined. The purpose of this study was to determine the causes and clinical presentations of rib fractures in infants <12 months old., Methods: Retrospectively, we identified all infants with rib fractures under 12 months old over a 3-year period using computerized databases at the Children's Hospital Medical Center in Cincinnati, Ohio and at the Children's Hospital, Winnipeg, Manitoba, Canada. Data extracted from the individual patient charts included: age, sex, chief complaint, number and location of rib fractures, associated injuries, birth history, history of cardiopulmonary resuscitation, and any evidence of bone dysplasia. After the chart review and a review of the radiographs by a pediatric radiologist, all fractures were determined to be attributable to one of the following causes: child abuse, birth injury, bone fragility, or accidental trauma. A determination of abuse was made when there were other injuries indicative of abuse, there was no clinical or radiographic evidence of bone fragility, there was a confession of abuse, when no reasonable history of trauma was provided, or when the history was not plausible to explain the rib fractures. Standard practice at these hospitals involves obtaining skeletal surveys on all children <2 years old when abuse is suspected. The child abuse team, which consists of physicians, nurses, and social workers, conducts these investigations and works closely with police in evaluating these children., Results: Thirty-nine infants with rib fractures were identified. Thirty-two (82%) were caused by child abuse. Three (7. 7%) were attributable to accidental injuries, 1 (2.6%) was secondary to birth trauma, and 3 (7.7%) were attributable to bone fragility. All 3 infants with fractures from accidental injury had sustained notable trauma (a motor vehicle collision, a forceful direct blow, and a fall from a height). Of the 3 infants with fractures secondary to bone fragility, 1 infant had osteogenesis imperfecta, 1 infant had rickets, and 1 infant, who was born at 23 weeks' gestation, had fragile bones attributable to prematurity., Conclusions: Most rib fractures in infants are caused by child abuse. Although much less common, rib fractures can also occur after serious accidental injuries, birth trauma, or secondary to bone fragility. A thorough clinical and imaging evaluation is mandatory.

Objective: This study examined the prevalence of gonorrhea in girls <12 years of age who presented with vaginitis and in whom sexual abuse was not suspected., Design: A prospective, consecutive patient series was performed in a pediatric emergency department with 90 000 visits per year and in 2 affiliated pediatric continuity clinics. All girls (Tanner I or II) between the ages of 12 months and 12 years, presenting with a chief complaint of vaginal discharge, burning, pain, or itching, were enrolled (n = 93). Patients were excluded (n = 6) if there was a history of sexual abuse. The presence or absence of vaginal discharge, vaginal erythema, or trauma was recorded. Physicians were instructed to collect cultures for Neisseria gonorrhea (GC), Chlamydia trachomatis, and bacteria/yeast. Wet prep, urinalysis, urine culture, serum rapid plasma reagin, and fungal culture were obtained at the physician's discretion., Results: Of the girls, 43 had a vaginal discharge on examination. Of these girls, 4 (9%) had GC, 9 (26%) had group A, B, or F streptococcus and 1 had Staphylococcus aureus. Of the girls, 44 had no discharge on examination. In this group, 3 had streptococcus infection and 2 had Candida albicans. Both children with C albicans had been treated recently with systemic antibiotics. Those girls with a vaginal discharge on examination had a microbial etiology significantly more often than did those without discharge. All of the girls with infection were Tanner I on genital examination., Conclusions: The prevalence of unsuspected GC infection was high and emphasizes the importance of culturing Tanner I girls for GC when they have a vaginal discharge along with routine bacterial cultures. Testing and/or treating for C albicans should be considered when there has been recent antibiotic use. Girls with vaginal complaints but without vaginal discharge may have a bacterial infection, but such diagnoses occur less frequently than with girls who have a discharge.

Objective: To determine the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, syphilis, and human immunodeficiency virus (HIV) infection in sexually abused children and to develop selective criteria for sexually transmitted disease (STD) testing in these children in our community., Design: Prospective., Setting: University-affiliated children's hospital in Ohio., Participants: All children evaluated at our hospital for sexual abuse were eligible. Eight hundred fifty-five children were evaluated over a 1-year period. The study included 704 girls and 151 boys. Children ranged in age from 3 weeks to 18 years old., Methods and Results: Standard STD testing (American Academy of Pediatrics recommendations) was defined as serum rapid plasma reagin test, examination for Trichomonas, N gonorrhoeae culture of the throat, rectum, and genitalia and C trachomatis culture of the rectum and genitalia. STD testing in this study was recommended in children with 1) a history of genital discharge or contact with the perpetrator's genitalia, 2) examination findings of genital discharge or trauma, and 3) all adolescents. HIV testing was obtained in children with risk factors for HIV infection, those with contact with a perpetrator with HIV risk factors, or if the family was concerned about HIV acquisition. A total of 423 children were tested for N gonorrhoeae, 415 for C trachomatis, 275 for syphilis, 208 for Trichomonas, and 140 for HIV. Twelve children were determined to have N gonorrhoeae infection, 11 had C trachomatis infection, and four had Trichomonas infection. Overall, the prevalence of STDs in prepubertal girls was 3.2% and 14.6% in pubertal girls. The prevalence of N gonorrhoeae in prepubertal girls with vaginal discharge was 11.1% and 0% in prepubertal girls without discharge (P < .001). C trachomatis infection was diagnosed in 0.8% of prepubertal girls compared with 7.0% of pubertal girls (P < .001). None of the children tested positive for syphilis or HIV and no males had a STD., Conclusions: In our community, N gonorrhoeae testing in prepubertal girls can be limited to those with a vaginal discharge on examination unless other risk factors are present. The prevalence C trachomatis and Trichomonas in prepubertal girls is low and may be omitted from routine evaluations. All pubertal girls evaluated for sexual abuse should be tested for STDs because of the high prevalence of asymptomatic infection in this patient population.

Objective: To determine the occurrence and frequency of abuse in children with humeral fractures without immediately obvious etiologies who are less than 3 years old and present with arm injuries., Methods: A retrospective chart review was conducted of all children less than 3 years old treated for a humeral fracture at Children's Hospital Medical Center between July 1, 1990, and September 10, 1993. One hundred twenty-four charts of children with humeral fractures were reviewed for possible abuse using previously developed criteria. Charts were evaluated independently by the investigators. Consensus was reached on classification of each chart into the following categories: abuse, indeterminate, or not abuse., Results: Abuse was diagnosed in 9 of 25 (36%) children less than 15 months of age, but in only 1 of 99 (1%) children older than 15 months (P < .05). Abuse was excluded in 91 of 124 (73%) children. No determination of abuse (indeterminate) could be made in 23 of 124 (18.5%) children. In children less than 15 months of age, abuse was diagnosed in 2 of 10 (20%) with supracondylar fractures and in 7 of 12 (58%) with spiral/oblique fractures., Conclusion: The prevalence of abuse in our children presenting with humeral fractures was much lower than in other published reports, especially in the children over the age of 15 months. However, we found a higher prevalence of supracondylar fractures associated with abuse than those same reports. Given these findings, abuse should be considered in all children less than 15 months of age with humeral fractures, including those with supracondylar fractures. The majority of humeral fractures in children are accidental, especially beyond the age of 15 months.

A prospective study of the effects of fever reduction on the clinical appearance of infants at risk for occult bacteremia was undertaken to study the hypothesis that infants with bacteremic illness fail to improve clinically following defervescence compared with infants with benign viral illness. A total of 154 children were enrolled in the study, including 19 with bacteremia: 13 with occult Streptococcus pneumoniae bacteremia, two with occult Haemophilus influenzae, type b bacteremia, and four with Haemophilus meningitis and bacteremia. There were no differences in degree of temperature reduction with acetaminophen between the bacteremic and nonbacteremic groups of infants. Among infants with bacteremia but without meningitis, differences from nonbacteremic children were detected in clinical appearance prior to fever reduction but not following defervescence. All patients with meningitis appeared seriously ill before and after defervescence. It was concluded that clinical improvement with defervescence is not a reliable indicator of the presence of occult bacteremia. Lack of clinical improvement with defervescence may be a reliable indicator for the presence of meningitis. Because there were differences in clinical appearance prior to fever reduction, routine administration of acetaminophen may interfere with the clinical evaluation by the physician.