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This study describes a hospital-based child abuse pediatrics consultation service. Medical records for all child abuse pediatrics consultations during 2006 to 2009 were reviewed. Descriptive statistics were used for data analysis. Of 2495 consultations, 13 were excluded due to insufficient information, 1682 were examinations for suspected sexual abuse, and 800 were examinations for nonsexual abuse concerns. Among the latter group of 800 patients, the most common reasons for consultation were fracture (33.5%), nonburn skin injury (16.8%), burn (15.4%), and intracranial injury (13.2%). Median patient age was 11 months (range = 3 days to 16 years). Case fatality rate was 3.9%. Final diagnosis was classified as definite/likely abuse in 40.0%, questionable/unknown in 24.5%, definite/likely accident in 23.6%, no injury in 4.6%, neglect in 4.0%, and a medical condition in 3.2%. Therefore, among consultations requested for suspected child maltreatment, a child abuse pediatrician concluded that abuse was definite or likely in less than half of patients.

BACKGROUND AND PURPOSE: MR imaging with sedation is commonly used to detect intracranial traumatic pathology in the pediatric population. Our purpose was to compare nonsedated ultrafast MR imaging, noncontrast head CT, and standard MR imaging for the detection of intracranial trauma in patients with potential abusive head trauma. MATERIALS AND METHODS: A prospective study was performed in 24 pediatric patients who were evaluated for potential abusive head trauma. All patients received noncontrast head CT, ultrafast brain MR imaging without sedation, and standard MR imaging with general anesthesia or an immobilizer, sequentially. Two pediatric neuroradiologists independently reviewed each technique blinded to other modalities for intracranial trauma. We performed interreader agreement and consensus interpretation for standard MR imaging as the criterion standard. Diagnostic accuracy was calculated for ultrafast MR imaging, noncontrast head CT, and combined ultrafast MR imaging and noncontrast head CT. RESULTS: Interreader agreement was moderate for ultrafast MR imaging (κ = 0.42), substantial for noncontrast head CT (κ = 0.63), and nearly perfect for standard MR imaging (κ = 0.86). Forty-two percent of patients had discrepancies between ultrafast MR imaging and standard MR imaging, which included detection of subarachnoid hemorrhage and subdural hemorrhage. Sensitivity, specificity, and positive and negative predictive values were obtained for any traumatic pathology for each examination: ultrafast MR imaging (50%, 100%, 100%, 31%), noncontrast head CT (25%, 100%, 100%, 21%), and a combination of ultrafast MR imaging and noncontrast head CT (60%, 100%, 100%, 33%). Ultrafast MR imaging was more sensitive than noncontrast head CT for the detection of intraparenchymal hemorrhage (P = .03), and the combination of ultrafast MR imaging and noncontrast head CT was more sensitive than noncontrast head CT alone for intracranial trauma (P = .02). CONCLUSIONS: In abusive head trauma, ultrafast MR imaging, even combined with noncontrast head CT, demonstrated low sensitivity compared with standard MR imaging for intracranial traumatic pathology, which may limit its utility in this patient population.

Objective To measure the yield of a skeletal survey in children ≤18 months old presenting with isolated skull fractures without significant intracranial injury. Study design A retrospective chart review was conducted on all children ≤18 months old presenting with an isolated skull fracture not associated with a motor vehicle crash or shopping cart fall between January 1, 2004 and December 31, 2010. An institutional protocol requires a skeletal survey and social work consult on all such children. We analyzed the association of mechanism of injury, type of skull fracture, and presence of “red flags” with a positive skeletal survey using χ2 and Fisher exact tests. Results Of 175 eligible patients, 150 (86%) underwent a skeletal survey. Of the 9 patients (6%) who had another fracture in addition to the presenting one, only 1 child was older than 6 months. Eight patients with additional fractures had a simple skull fracture (not complex) and 7 patients with other fractures had at least 1 red flag. Regarding skull fractures, the majority of long falls (81%) resulted in a simple skull fracture. Conclusion The skeletal survey in patients with isolated skull fractures revealed additional fractures in 6% of patients. Thus, a skeletal survey may yield clinically and forensically relevant data in such patients. However, it may be possible to restrict the window for obtaining a skeletal survey to younger infants, particularly those who are premobile.

Pediatric head trauma, including abusive head trauma, is a significant cause of morbidity and mortality. The purpose of this research was to identify and evaluate radiologic interpretation errors of head CTs performed on abusive and non-abusive pediatric head trauma patients from a community setting referred for a secondary interpretation at a tertiary pediatric hospital. A retrospective search identified 184 patients

The objective of our study was to evaluate the prevalence and site of fractures detected on skeletal surveys performed for suspected child abuse at a tertiary children's hospital and to determine whether any survey images may be eliminated without affecting clinical care or the ability to make a diagnosis.We identified all skeletal surveys performed for suspected abuse from 2003 to 2009 of children younger than 2 years. Repeated studies were excluded, as were studies not performed to evaluate for suspected abuse. From the reports, we documented the sites of all the fractures. RESULTS. Nine hundred thirty children (515 boys and 415 girls) with a median age of 6 months met the entry criteria for the study. Fractures were detected in 317 children (34%), of whom 166 (18%) had multiple fractures. The most common sites for fractures were the long bones (21%), ribs (10%), skull (7%), and clavicle (2%). Ten children (1%) had fractures in the spine (n = 3), pelvis (n = 1), hands (n = 6), and feet (n = 2). All 10 children had other signs of physical abuse.In skeletal surveys performed for suspected child abuse, fractures limited to sites other than the long bones, ribs, skull, and clavicles are rare. The additional radiation exposure and cost of obtaining radiographs of the spine, pelvis, hands, and feet may outweigh their potential benefit. Given the rarity of fractures of the spine, pelvis, hands, and feet, consideration may be given to eliminating those views from routine skeletal surveys performed to evaluate for suspected child abuse.

OBJECTIVE:Consensus recommendations state that a radiographic skeletal survey is mandatory for all children METHODS:We performed retrospective analyses of data collected as part of the Using Liver Transaminases to Recognize Abuse (ULTRA) research network. Data were collected for all children RESULTS:Of 97 children CONCLUSION:The rate of fractures in children who present with burns and concerns regarding physical abuse is sufficient to support the recommendation for routinely performing skeletal surveys for children

To determine the frequency of occult fractures in children with suspicious burns compared with children with other types of physical abuse.Child abuse outpatient clinic reports and inpatient consultations from a midwest urban children's hospital for 1989 to 2000 were reviewed. Demographic and clinical data were abstracted for patients seen because of suspected physical abuse. Patients were classified based on reason seen (burns vs other physical injuries), whether they were diagnosed as abused, and whether they had at least 1 skeletal survey. Positive skeletal surveys were defined as having a fracture that was unexplained, highly specific for abuse, or with a perpetrator confession.Of 335 patients evaluated, the mean age (+/-SD) was 1.5 +/- 1.9 years, 63% were boys, 64% were white, and 80% had skeletal surveys performed. Reasons for evaluation included 69 (21%) for burns and 266 (79%) for other injuries. After excluding patients without a final diagnosis of abuse and those presenting with obvious fractures, 5 (14%) of 36 burn patients had positive skeletal surveys compared with 45 (34%) of 133 with nonburn injuries (P = 0.02). Burn patients were older compared with those with nonburn injuries (mean ages, 1.8 +/- 1.5 vs. 1.1 +/- 1.6 years; P = 0.03) and were more likely to be nonwhite (69% vs. 32%; P0.001).Although young children with abusive burns have fewer occult fractures compared with those with other abusive injuries, the frequency of occult fractures is still high enough to warrant the consideration of skeletal surveys in these cases.

OBJECTIVE. Distal humeral epiphyseal separation is rare and often misdiagnosed. The purpose of this study was to summarize an experience with radiography and ultrasound of distal humeral epiphyseal separation. MATERIALS AND METHODS. The records of all children younger than 36 months with the diagnosis of distal humeral epiphyseal separation from 2006 to 2013 were identified. Medical and imaging records were reviewed for diagnosis with radiography and ultrasound, cause, treatment, and follow-up. The initial diagnosis, relation of the radius and ulna to the distal humerus, presence of other fractures, and signs of elbow effusion were evaluated. RESULTS. Sixteen patients (10 boys, six girls; mean age, 8.6 months) were evaluated for distal humeral epiphyseal separation. All patients had elbow radiographs. Fifteen (94%) patients had medial and six (38%) had posterior displacement of the radius and ulna. The diagnosis was missed on radiographs of nine (56%) patients. Ultrasound was performed for 12 patients and showed distal humeral epiphyseal separation in all. In 10 (63%) patients, one or more additional humeral fractures were found: bucket-handle fractures in five patients and condylar avulsion fracture in six patients. In the six (38%) patients younger than 1 month, distal humeral epiphyseal separation was secondary to birth trauma. In 4 of the 10 (40%) older patients, nonaccidental trauma was diagnosed. All patients underwent follow-up with a pediatric orthopedist and had full range of motion. Two patients had mild varus deformities. CONCLUSION. The diagnosis of distal humeral epiphyseal separation is often missed on radiographs. Radiologists should be aware that posteromedial displacement of the radius and ulna in young children is highly suggestive of distal humeral epiphyseal separation and that the diagnosis can be confirmed with ultrasound.

Objective.To determine the frequency of court appearance by pediatricians evaluating child abuse and neglect cases and to identify case characteristics associated with actual court appearance or case adjournment.Design.Retrospective review of subpoenas received between 1995 and 1999 for child maltreatment cases personally evaluated by 2 pediatricians during the years 1995 to 1998. Information was collected regarding patient age, gender, race/ethnicity, type of suspected maltreatment, date of evaluation, date of subpoena, type of court hearing, whether the pediatrician actually testified in court, and legal outcomes. Case characteristics were compared between pediatricians and were used to predict physician appearance and case continuance or adjournment in logistic regression models.Results.Four hundred forty-five subpoenas concerning 260 patients were received. Although significant differences were noted between the pediatricians in type of abuse, no differences were found in patient age, gender, ethnicity or legal outcomes. The pediatricians received subpoenas in Conclusions.Although pediatricians are sometimes subpoenaed to appear in court to explain the medical evaluation and the needs of the child in cases of child abuse and neglect, most court cases were continued, adjourned, or settled before physician testimony. Most subpoenas did not result in the pediatrician going to court, and it is unclear which child factors may predict court involvement. Pediatricians can take steps to minimize (but not eliminate) the potential dissatisfaction and inconvenience associated with receiving and responding to subpoenas in child maltreatment cases.

Subconjunctival hemorrhages in infants and children can be a finding after nonaccidental trauma. We describe 14 children with subconjunctival hemorrhages on physical examination, who were subsequently diagnosed by a child protection team with physical abuse. Although infrequent, subconjunctival hemorrhage may be related to abuse. Nonaccidental trauma should be on the differential diagnosis of subconjunctival hemorrhage in children, and consultation with a child abuse pediatrics specialist should be considered.

During the past 150 years, native C 3 shrubs have invaded and dominated extensive areas of former C 4 grasslands in deserts of the south-western United States. This vegetation shift has caused large changes in several aspects of the structure and function of these plant communities. To examine structural changes, we measured the standing crop of green herbaceous plants and live shrubs, leaf area index (LAI), and canopy cover and shrub density in grass and shrub plant communities that exist on sandy and clay soils in the Chihuahuan Desert. Standing crop ranged from 800 to 1800 kg ha −1 for grass communities and from 2800 to 3500 kg ha −1 for shrub communities. The LAI in grass communities was typically 0·1 to 0·2 and in shrub communities was 0·3 to 0·4. Averaged over the 2 years, the greatest LAI was in the shrub community on a clay soil that also had a herbaceous understory. Shrub canopy cover varied from 17% ( Flourensia cernua , tarbush) to 33% ( Prosopis glandulosa , honey mesquite). On sandy soils, this vegetation shift has resulted in a replacement of herbaceous vegetation with shrubs and a large reduction in species diversity, while on clay soils, due to greater soil fertility and soil water availability, there was only a slight decrease in herbaceous vegetation and little change in species diversity. This vegetation shift of desert grasslands has dramatically changed plant community structure.

During the past 150 years, the C3shrubs creosotebush [Larrea tridentata(DC.) Cov.], mesquite [Prosopis glandulosaTorr. var.glandulosa], and tarbush (Flourensia cernuaDC.) have invaded extensive areas of former C4grasslands in deserts of the south-western United States. We measured energy balance components of these grass and shrub communities in the Chihuahuan Desert. Midday net radiation in theP. glandulosacommunity was about 20% less than that in the others, where it was about equal. Midday soil heat flux was large in all communities and was greater in communities with small leaf areas. Midday and daily latent heat fluxes (or evapo-transpiration rates, ET) were about equal in all communities except theF. cernuacommunity, where they were about 50% greater due to greater leaf area and water supply. The fraction of ET made up of soil evaporation varied from 0·3 to 0·6 and was greater inL. tridentataandP. glandulosacommunities. Differences of surface energy balance components of plant communities in this desert environment were generally small and were more related to surface characteristics (e.g. leaf area) and water supply than to photosynthetic pathway or vegetation type.

ACR guidelines for routine skeletal survey for child abuse recommend only AP radiographs of the long bones; however, many institutions add lateral radiographs. To evaluate whether adding lateral radiographs for long bones changes the frequency and confidence of fracture detection in skeletal survey radiographs for suspected abuse. We identified 100 children younger than 2 years of age who underwent skeletal survey for child abuse; 56 with multiple long bone fractures, 22 with a single fracture and 22 with no fractures. Four radiologists (two pediatric radiologists, one pediatric radiology fellow and one general radiologist) evaluated two randomized series (one series included only frontal, and the other series, frontal and lateral radiographs). Likert scale of 1–5 was used to score for detection of metaphyseal and diaphyseal fractures. For combined readers, significantly more metaphyseal fractures (P = 0.01) were detected with the two-views series of radiographs compared with the frontal-only view; there was no significant difference for diaphyseal fractures. Confidence was also significantly higher for the two-views series. Kappa improved (from 0.32 to 0.48) when the lateral view was added only for the metaphyseal fractures. Adding lateral radiographs resulted in increased detection and confidence levels of metaphyseal fractures.

Medical, social service and coroner reports were reviewed for 14 cases of fatal child abuse and neglect identified at a children's hospital from 1988-1992. Twelve cases involved physical abuse and two neglect. The median age was 6.5 months (range 24 days to 3 years). Six families (43%) had prior protective service involvement; however, four of the referrals involved a sibling. Only two of 12 physical abuse victims had a history of a prior suspicious injury. Clinical and postmortem findings are presented. The cause of death in all physically abused patients was blunt impact head injury; one also had contributing intraabdominal injuries. Ten cases were ruled due to homicide; 12 have come to legal closure resulting in nine felony convictions. These findings emphasize the role of blunt impact brain injury in fatal child abuse cases. Two findings have significant implications for prevention: (a) the paucity of injuries recognized prior to the fatal event, and (b) among families known to child protection agencies the focus was not the fatally injured child.

A two-year, eight-month-old boy was diagnosed clinically with perianal warts and treated with topical 5-Fluorouracil, with subsequent resolution of the lesions. The child disclosed sexual abuse, and subsequent physical abuse was also documented. Attempts to identify the perpetrator have been hampered by the child's young age and resolution of the skin lesions. The forensic implications of this case are discussed. Language: en

Seroprevalence of hepatitis B virus markers was examined in employees participating in patient care at The Children's Mercy Hospital in Kansas City, Missouri. Of 377 workers tested in 1985-86, 36 (9.6%) were seropositive for any marker. Among 285 employees who presumably have only work-related hepatitis B exposure, 14 (4.9%) were seropositive. Age 50 years and older, black race, and education no more than 12 years were associated with seropositivity among workers with work-related exposure. Employees in the clinics, laboratories, emergency room, and operating room had an increased prevalence of hepatitis B markers compared to those in other work locations (8 vs. 2%, p < 0.05). Traditional risk factors for infection were not predictive of seropositivity. Although the risk of acquiring hepatitis B infection from employment in a children's hospital is low, this study does identify work-related risk factors. Possible reasons for this association are discussed.

A cost-benefit analysis of routine active immunization against hepatitis B virus (HBV) for 500 nursing personnel at The Children's Mercy Hospital in Kansas City, Missouri, is described. Based on outcomes of HBV infection, local charges for medical care and wages lost from illness, the authors calculate the average cost per case of HBV infection to be $1,990. Including the current system of postexposure prophylaxis and an annual attack rate of 1 percent the current annual cost of HBV infection in The Children's Mercy Hospital is $12,630. The HBV immunization program would have to continue for 15 years before its cumulative costs ($189,133) were exceeded by those of the current system ($189,450). Therefore routine immunization of nurses would not be cost effective in the near future. If, however, a subset of high-risk employees with a 2 percent attack rate is identified, or the cost of the HBV vaccine series fell from the current $103 to $27, then routine immunization would become cost beneficial within 6 years.

Twenty-nine intubated pediatric patients were prospectively studied to determine whether nontypable Haemophilus influenzae (NTHI) is associated with the development of nosocomial pneumonia. Throat cultures and tracheal Gram stains, leukocyte counts and cultures were obtained immediately following intubation, then serial studies on tracheal secretions were performed. Median patient age was 13 months. One patient had preexisting lung disease and 14 (48%) had pneumonia when intubated. There were five deaths. NTHI was recovered from the initial throat or tracheal culture in seven patients (24%); none developed a nosocomial lower respiratory tract infection. NTHI was not associated with any of three cases of nosocomial pneumonia. Three of 12 NTHI isolates were beta-lactamase producers. Tracheal leukocyte counts and Gram stains were not predictive of pneumonia, either at the time of intubation or subsequently. We conclude that NTHI in the oropharynx or trachea is not predictive of pneumonia among intubated pediatric patients.

During a 2-year period after the introduction of an intensive chemotherapeutic protocol, alpha-hemolytic streptococci accounted for 75% of all episodes of sepsis among children with acute nonlymphocytic leukemia at our institution. Only one case had occurred in the previous 8 years. Fourteen of 15 episodes of streptococcal sepsis occurred after therapy with either continuous or large dosage intermittent cytosine arabinoside. Eleven episodes occurred at two specific treatment points. Septic episodes were complicated by shock (2 of 15), encephalopathy (2 of 15), pneumonia (3 of 15) and death (1 of 15). Oral mucosal lesions may provide a portal of entry for alpha-hemolytic streptococci. These data suggest that children receiving continuous or large dosage intermittent cytosine arabinoside for treatment of acute nonlymphocytic leukemia may be at increased risk for alpha-hemolytic streptococcal sepsis. Empiric antimicrobial therapy in these children when febrile and neutropenic should include antibiotics effective against alpha-hemolytic streptococci.