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Zamalin D, Hamlin I, Shults J, Katherine Henry M, Campbell KA, Anderst JD, Bachim AN, Berger RP, Frasier LD, Harper NS, Letson MM, Melville JD, Lindberg DM, Wood JN. Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation. Acad Pediatr 2024; 24:78-86. [PMID: 37178908 PMCID: PMC10638459 DOI: 10.1016/j.acap.2023.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). METHODS Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. CONCLUSIONS Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.
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Affiliation(s)
- Danielle Zamalin
- Department of Pediatrics (D Zamalin), Kravis Children's Hospital, Icahn School of Medicine, Mount Sinai Hospital, New York, NY.
| | - Irene Hamlin
- Perelman School of Medicine (I Hamlin), University of Pennsylvania, Philadelphia, Pa.
| | - Justine Shults
- Department of Biostatistics, Epidemiology (J Shults), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa.
| | - M Katherine Henry
- Division of General Pediatrics, Clinical Futures, and PolicyLab (M Katherine Henry), Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 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.
| | - 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.
| | - Lori D Frasier
- Department of Pediatrics (LD Frasier), Penn State Children's Hospital, Penn State Hershey College of Medicine, Hershey, Pa; Penn State Hershey Medical Center (LD Frasier), Center for the Protection of Children, Hershey, Pa.
| | - Nancy S Harper
- University of Minnesota School of Medicine (NS Harper), Center for Safe and Healthy Children, Minneapolis, Minn.
| | - Megan M Letson
- Nationwide Children's Hospital (MM 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.
| | - Daniel M Lindberg
- Department of Emergency Medicine (DM Lindberg), The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, Aurora, Colo.
| | - 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, Philadelphia, Pa.
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Greenbaum J, Sprang G, Recknor F, Harper NS, Titchen K. Labor trafficking of children and youth in the United States: A scoping review. Child Abuse Negl 2022; 131:105694. [PMID: 35749904 DOI: 10.1016/j.chiabu.2022.105694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Child labor trafficking is a largely unexplored and unpublished phenomenon in the United States. OBJECTIVE To 1) characterize the state of the science on child labor trafficking, and 2) identify empirical information regarding risk and protective factors, and physical/behavioral health needs of labor-trafficked children/adolescents. METHODS This scoping review involved an electronic review of five databases; the search was restricted to studies in English or Spanish and published between Jan 1, 2010-Oct 16, 2020. The search yielded 1190 articles; 48 studies qualified for full review and 8 met inclusion criteria (US-based study addressing risk factors/vulnerabilities for child labor trafficking; protective factors; health impact; or health/behavioral healthcare). RESULTS Only one study had sufficient sample size to compare sex to labor trafficking among minors; some did not separate data by age group or by type of trafficking. A few shared data from a common source; one was a single case review. Findings suggested that sex and labor trafficking may share common risk factors (e.g., prior child maltreatment and out-of-home placement) as well as within group differences (e.g., labor trafficked children had less prior child welfare involvement than those involved in sex trafficking and were more likely to be younger, male, Black or non-white, and Hispanic). Multiple physical/behavioral health symptoms were reported and may be useful items for a healthcare screen. CONCLUSIONS Child labor trafficking research in the U.S. is in its infancy, although the results of this review point to opportunities for screening and case conceptualization that may be useful to practitioners.
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Affiliation(s)
- Jordan Greenbaum
- International Centre for Missing and Exploited Children, 2318 Mill Road, Suite 1010, Alexandria, VA 22314, USA; Stephanie V. Blank Center for Safe and Healthy Children at Children's Healthcare of Atlanta, 975 Johnson Ferry Rd, NE, Atlanta, GA 93342, USA.
| | - Ginny Sprang
- University of Kentucky, College of Medicine/Department of Psychiatry, Center on Trauma and Children, 3470 Blazer Parkway Suite 100, Lexington, KY 40509, USA.
| | - Frances Recknor
- Baylor College of Medicine, Menninger Department of Psychiatry, Anti-Human Trafficking Program, One Baylor Plaza, MS 350, Houston, TX 77030, USA.
| | - Nancy S Harper
- Otto Bremer Trust Center for Safe and Healthy Children, University of Minnesota, Department of Pediatrics, USA; University of Minnesota Masonic Children's Hospital, 1st Floor Suite R107, 2512 S 7th Street, Minneapolis, MN 55454, USA.
| | - Kanani Titchen
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UC San Diego/Rady Children's Hospital, 3020 Children's Way MC 5165, San Diego, CA 92123, USA.
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Peterson LJ, Foell R, Lunos S, Heisterkamp B, Greenbaum VJ, Harper NS. Implementation of a screening tool for child sex trafficking among youth presenting to the emergency department - A quality improvement initiative. Child Abuse Negl 2022; 125:105506. [PMID: 35091304 PMCID: PMC8862543 DOI: 10.1016/j.chiabu.2022.105506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Identification of sex-trafficked youth in the emergency department (ED) is difficult and routine screening is uncommon. OBJECTIVES Our Quality Improvement (QI) Project aimed to increase ED screening and identification of high-risk youth using the Short Screen for Child Sex Trafficking (SSCST). PARTICIPANTS Youth (11 through 17 years) seeking care at two metropolitan EDs with a high-risk chief complaint triggering a best practice alert (BPA). METHODS A BPA prompted administration of the SSCST and referral of screen 'positive' youth for comprehensive evaluation for child sex trafficking by the forensic nurse examiner (FNE). Targeted QI interventions defined three study periods (SP). Outcomes measures included screening 50% of high-risk youth with 50% of those youth referred for FNE evaluation. RESULTS Over three study periods, 5454/13,956 (39.1%) youth triggered a BPA for high-risk chief complaint; 4354 (78.6%) received the SSCST screen; 1336 (76.0%) of screen-positive youth were referred for FNE evaluation. Outcomes measures were exceeded during all three study periods. SSCST modifications to increase specificity led to a significant decrease in the percentage of positive screens (42.8% SP1 vs 29.4% SP3). Financial programmatic support and further staff training led to an increase in FNE evaluations (86.4 SP3 vs 5.7% of referred youth SP1). Identification of trafficked patients increased from 1.3% of screen-positive youth to 11.3% (SP1 vs SP3; p < 0.0001). CONCLUSIONS Routine screening for child sex trafficking can be implemented in the ED setting and increases the identification of at-risk youth.
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Affiliation(s)
- Loralie J Peterson
- Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, United States of America
| | - Rebecca Foell
- Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, United States of America
| | - Scott Lunos
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, United States of America
| | | | - V Jordan Greenbaum
- International Centre for Missing and Exploited Children, United States of America
| | - Nancy S Harper
- Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, United States of America.
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George CL, Harper NS. Computer Algorithms Support Physician Decisions in Traumatic Head Injury. Pediatrics 2022; 149:183817. [PMID: 34890452 PMCID: PMC9645695 DOI: 10.1542/peds.2021-054009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Caroline L.S. George
- Address correspondence to Caroline L.S. George, MD, Otto Bremer Trust Center for Safe and Healthy Children, University of Minnesota, 2512 S 7th St, Suite R107, Minneapolis, MN 55454. E-mail:
| | - Nancy S. Harper
- Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children’s Hospital, Minneapolis
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George CLS, Theesfeld SSN, Wang Q, Hudson MJ, Harper NS. Identification and Characterization of Oral Injury in Suspected Child Abuse Cases: One Health System's Experience. Pediatr Emerg Care 2021; 37:494-497. [PMID: 30601344 DOI: 10.1097/pec.0000000000001715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Accurately differentiating inflicted from accidental injury in infants and toddlers is critical. Many studies have documented characteristics of inflicted bruises, fractures, and head injuries facilitating the development of clinical tools. There are few studies characterizing inflicted oral injuries, and no clinical tools exist. This study identified characteristics that differentiated inflicted from accidental oral injuries in children younger than 24 months. METHODS Retrospective review using International Classification of Diseases, Ninth Revision billing codes and an internal clinical database tool identified children younger than 24 months between 2004 and 2014. Two groups were created according to the presence or absence of a child abuse diagnosis resulting in an accidental injury and suspected child abuse (SCA) group. Statistical analyses were performed on patient demographics, history of trauma, oral injury characterization, bruises, and fractures. RESULTS Billing codes were applied differently between the accidental injury and SCA groups, even when the same injury was described. Patients with SCA were younger and less mobile when compared with those with accidental injuries (P < 0.0001). Tongue injuries (P < 0.0001) and oropharynx bruising (P = 0.0018) were observed more and lacerations were observed less (P < 0.0001) in the SCA group. The SCA group was less likely to have a trauma history than those with accidental injury (P < 0.0001). CONCLUSIONS Several differences in patient characteristics, trauma history, injury type, and location were identified between the accidental versus SCA groups. A future clinical tool that incorporates age, history of trauma on presentation, tongue injury, and oropharynx bruising may assist medical providers in placing child physical abuse in the differential diagnosis.
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Affiliation(s)
- Caroline L S George
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital
| | - Samuel S N Theesfeld
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital
| | - Qi Wang
- Clinical and Translational Science Institute, University of Minnesota
| | | | - Nancy S Harper
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital
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Abstract
BACKGROUND Skull fractures are commonly seen after both accidental and nonaccidental head injuries in young children. A history of recent trauma may be lacking in either an accidental or nonaccidental head injury event. Furthermore, skull fractures do not offer an indication of the stage of healing on radiologic studies because they do not heal with callus formation as seen with long bone fractures. Thus, a better understanding on the timing of skull fracture resolution may provide guidance on the medical evaluation for accidental or nonaccidental head injury. OBJECTIVE The aim of the study was to determine the time required for radiographic skull fracture resolution in children younger than 24 months. METHODS This was a retrospective observational analysis of children younger than 24 months referred with skull fractures between January 2008 and December 2012. Analysis included children with accidental head injuries with a known time interval since injury and a negative skeletal survey who underwent serial radiographic studies. Complete healing of a skull fracture was defined as resolution of fracture lucency by radiograph. RESULTS Of the 26 children who met inclusion criteria, 11 (42.3%) demonstrated resolution of skull fracture(s) on follow-up imaging. Fracture resolution on radiologic studies ranged from 2 to 18 weeks. Twelve fractures in 10 children demonstrated fracture resolution at 10 or more weeks after injury. CONCLUSIONS Healing or resolution of a skull fracture can take months in children younger than 24 months. With the high variability in skull fracture presentation and large window to fracture resolution, unexplained or multiple skull fractures in children younger than 24 months may be the result of a single or multiple events of head trauma.
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Affiliation(s)
- Nancy S. Harper
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | | | | | | | - Laura J. Padhye
- Department of Family Medicine and Community Health, University of Minnesota, M Health Fairview St. Joseph's Hospital
| | - Loralie J. Peterson
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Michael A. Murati
- Department of Radiology, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Caroline L. S. George
- From the Department of Pediatrics, University of Minnesota, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
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Affiliation(s)
| | | | | | - Zuzan Cayci
- Department of Radiology University of Minnesota Masonic Children's Hospital Minneapolis, Minnesota
| | - David Nascene
- Department of Radiology University of Minnesota Masonic Children's Hospital Minneapolis, Minnesota
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Hymel KP, Herman BE, Narang SK, Graf JM, Frazier TN, Stoiko M, Christie LM, Harper NS, Carroll CL, Boos SC, Dias M, Pullin DA, Wang M. Reply. J Pediatr 2016; 171:321-2. [PMID: 26852180 DOI: 10.1016/j.jpeds.2016.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kent P Hymel
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Bruce E Herman
- University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, Utah
| | - Sandeep K Narang
- University of Texas Health Sciences Center at Houston, Houston, Texas
| | - Jeanine M Graf
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | | | | | | | - Nancy S Harper
- Driscoll Children's Hospital, Corpus Christi, Texas; University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | | | | | - Mark Dias
- Penn State College of Medicine, Hershey, Pennsylvania
| | | | - Ming Wang
- Penn State College of Medicine, Hershey, Pennsylvania
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Harper NS, Lewis T, Eddleman S, Lindberg DM. Follow-up skeletal survey use by child abuse pediatricians. Child Abuse Negl 2016; 51:336-342. [PMID: 26342432 DOI: 10.1016/j.chiabu.2015.08.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/10/2015] [Accepted: 08/12/2015] [Indexed: 06/05/2023]
Abstract
Skeletal survey is frequently used to identify occult fractures in young children with concern for physical abuse. Because skeletal survey is relatively insensitive for some abusive fractures, a follow-up skeletal survey (FUSS) may be undertaken at least 10-14 days after the initial skeletal survey to improve sensitivity for healing fractures. This was a prospectively planned secondary analysis of a prospective, observational study of 2,890 children who underwent subspecialty evaluation for suspected child physical abuse at 1 of 19 centers. Our objective was to determine variability between sites in rates of FUSS recommendation, completion and fracture identification among the 2,049 participants who had an initial SS. Among children with an initial skeletal survey, the rate of FUSS recommendation for sites ranged from 20% to 97%; the rate of FUSS completion ranged from 10% to 100%. Among sites completing at least 10 FUSS, rates of new fracture identification ranged from 8% to 28%. Among completed FUSS, new fractures were more likely to be identified in younger children, children with higher initial level of concern for abuse, and those with a fracture or cutaneous injury identified in the initial evaluation. The current variability in FUSS utilization is not explained by variability in occult fracture prevalence. Specific guidelines for FUSS utilization are needed.
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Affiliation(s)
- Nancy S Harper
- Center for Safe and Healthy Children, Child Abuse Pediatrics, University of Minnesota Masonic Children's Hospital, East Building, M653, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
| | - Terri Lewis
- Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, 13123 E. 16th Avenue, B390, Aurora, CO 80045, USA
| | - Sonja Eddleman
- Driscoll Children's Hospital, Child Abuse Resource and Evaluation Team, 3533 S Alameda, Corpus Christi, TX 78411, USA
| | - Daniel M Lindberg
- Department of Emergency Medicine, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado School of Medicine, 12401 E. 17th Avenue, B215, Aurora, CO 80045, USA
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Hymel KP, Herman BE, Narang SK, Graf JM, Frazier TN, Stoiko M, Christie LM, Harper NS, Carroll CL, Boos SC, Dias M, Pullin DA, Wang M. Potential Impact of a Validated Screening Tool for Pediatric Abusive Head Trauma. J Pediatr 2015; 167:1375-81.e1. [PMID: 26477871 DOI: 10.1016/j.jpeds.2015.09.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 06/23/2015] [Accepted: 09/03/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To conduct a retrospective, theoretical comparison of actual pediatric intensive care unit (PICU) screening for abusive head trauma (AHT) vs AHT screening guided by a previously validated 4-variable clinical prediction rule (CPR) in datasets used by the Pediatric Brain Injury Research Network to derive and validate the CPR. STUDY DESIGN We calculated CPR-based estimates of abuse probability for all 500 patients in the datasets. Next, we demonstrated a positive and very strong correlation between these estimates of abuse probability and the overall diagnostic yields of our patients' completed skeletal surveys and retinal examinations. Having demonstrated this correlation, we applied mean estimates of abuse probability to predict additional, positive abuse evaluations among patients lacking skeletal survey and/or retinal examination. Finally, we used these predictions of additional, positive abuse evaluations to extrapolate and compare AHT detection (and 2 other measures of AHT screening accuracy) in actual PICU screening for AHT vs AHT screening guided by the CPR. RESULTS Our results suggest that AHT screening guided by the CPR could theoretically increase AHT detection in PICU settings from 87%-96% (P < .001), and increase the overall diagnostic yield of completed abuse evaluations from 49%-56% (P = .058), while targeting slightly fewer, though not significantly less, children for abuse evaluation. CONCLUSIONS Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Medical Center, Salt Lake City, UT
| | - Sandeep K Narang
- Department of Pediatrics, University of Texas Health Science Center, Houston, TX
| | - Jeanine M Graf
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO
| | - Michael Stoiko
- Department of Pediatrics, DeVos Children's Hospital, Grand Rapids, MI
| | - LeeAnn M Christie
- Department of Critical Care, Dell Children's Medical Center of Central Texas, Austin, TX
| | - Nancy S Harper
- Children's Physician Services of South Texas, Driscoll Children's Hospital, Corpus Christi, TX
| | | | - Stephen C Boos
- Department of Pediatrics, Baystate Children's Hospital, Springfield, MA
| | - Mark Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, PA
| | - Deborah A Pullin
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Hymel KP, Armijo-Garcia V, Foster R, Frazier TN, Stoiko M, Christie LM, Harper NS, Weeks K, Carroll CL, Hyden P, Sirotnak A, Truemper E, Ornstein AE, Wang M. Validation of a clinical prediction rule for pediatric abusive head trauma. Pediatrics 2014; 134:e1537-44. [PMID: 25404722 DOI: 10.1542/peds.2014-1329] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To reduce missed cases of pediatric abusive head trauma (AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to validate the screening performance of this AHT CPR in a new, equivalent patient population. METHODS We conducted a prospective, multicenter, observational, cross-sectional study. Applying the same inclusion criteria, definitional criteria for AHT, and methods used in the completed derivation study, Pediatric Brain Injury Research Network investigators captured complete clinical, historical, and radiologic data on 291 acutely head-injured children <3 years of age admitted to PICUs at 14 participating sites, sorted them into comparison groups of abusive and nonabusive head trauma, and measured the screening performance of the AHT CPR. RESULTS In this new patient population, the 4-variable AHT CPR demonstrated sensitivity of .96, specificity of .46, positive predictive value of .55, negative predictive value of .93, positive likelihood ratio of 1.67, and negative likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified 98% of study patients who were ultimately diagnosed with AHT. CONCLUSIONS Four readily available variables (acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture) identify AHT with high sensitivity in young, acutely head-injured children admitted to the PICU.
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Pediatrics, and
| | - Veronica Armijo-Garcia
- Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Robin Foster
- Department of Emergency Medicine, Children's Hospital of Richmond at Virginia Commonwealth University Health System, Richmond, Virginia
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Michael Stoiko
- Department of Pediatrics, DeVos Children's Hospital, Grand Rapids, Michigan
| | - LeeAnn M Christie
- Department of Critical Care, Dell Children's Medical Center of Central Texas, Austin, Texas
| | - Nancy S Harper
- Children's Physician Services of South Texas, Driscoll Children's Hospital, Corpus Christi, Texas; Department of Pediatrics, University of Minnesota Children's Hospital, Minneapolis, Minnesota
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Phil Hyden
- Department of Pediatrics, Children's Hospital of Central California, Madera, California
| | - Andrew Sirotnak
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Edward Truemper
- Department of Pediatrics, Children's Hospital of Omaha, Omaha, Nebraska; and
| | - Amy E Ornstein
- Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia
| | - Ming Wang
- Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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14
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Abstract
Medical providers need to monitor growth at every visit. Weight status is influenced by genetics, medical conditions, socioeconomic status, and family environment. Screening for food security and psychosocial risk factors is an integral tool to identify families at risk for nutritional deficits and child maltreatment. Nutritional rehabilitation is best accomplished in an outpatient, multidisciplinary setting. Medical neglect should be considered in failure to thrive and obesity when there is a serious risk of harm from identified medical complications, additional or worsening medical complications occurring despite a multidisciplinary approach, and/or non-adherence with the treatment plan.
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Affiliation(s)
- Nancy S Harper
- Children's Physician Services of South Texas, Driscoll Children's Hospital, 3533 South Alameda, Corpus Christi, TX 78411, USA.
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15
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Harper NS, Feldman KW, Sugar NF, Anderst JD, Lindberg DM. Additional injuries in young infants with concern for abuse and apparently isolated bruises. J Pediatr 2014; 165:383-388.e1. [PMID: 24840754 DOI: 10.1016/j.jpeds.2014.04.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/04/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising. STUDY DESIGN This was a prospectively planned secondary analysis of an observational study of children<10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants<6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders. RESULTS Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse. CONCLUSIONS Infants younger than 6 months of age with bruising prompting subspecialty consultation for abuse have a high risk of additional serious injuries. Routine medical evaluation for young infants with bruises and concern for physical abuse should include physical examination, skeletal survey, neuroimaging, and abdominal injury screening.
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Affiliation(s)
- Nancy S Harper
- Children's Physician Services of South Texas, Driscoll Children's Hospital, Corpus Christi, TX.
| | - Kenneth W Feldman
- Children's Protection Program, Odessa Brown Children's Clinic, Seattle Children's Hospital, University of Washington
| | - Naomi F Sugar
- Seattle Children's Hospital, University of Washington, Seattle, WA
| | - James D Anderst
- Division of Child Abuse and Neglect, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, MO
| | - Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Kempe Center for the Prevention and Treatment of Child Abuse, Department of Pediatrics, Children's Hospital of Colorado, Aurora, CO
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16
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Lindberg DM, Berger RP, Reynolds MS, Alwan RM, Harper NS. Yield of skeletal survey by age in children referred to abuse specialists. J Pediatr 2014; 164:1268-73.e1. [PMID: 24630357 DOI: 10.1016/j.jpeds.2014.01.068] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/04/2013] [Accepted: 01/29/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine rates of skeletal survey completion and injury identification as a function of age among children who underwent subspecialty evaluation for concerns of physical abuse. STUDY DESIGN This was a retrospective secondary analysis of an observational study of 2609 children <60 months of age who underwent evaluation for possible physical abuse. We measured rates of skeletal survey completion and fracture identification for children separated by age into 6-month cohorts. RESULTS Among 2609 subjects, 2036 (78%) had skeletal survey and 458 (18%) had at least one new fracture identified. For all age groups up to 36 months, skeletal survey was obtained in >50% of subjects, but rates decreased to less than 35% for subjects >36 months. New fracture identification rates for skeletal survey were similar between children 24-36 months of age (10.3%, 95% CI 7.2-14.2) and children 12-24 months of age (12.0%, 95% CI 9.2-15.3) CONCLUSIONS: Skeletal surveys identify new fractures in an important fraction of children referred for subspecialty consultation with concerns of physical abuse. These data support guidelines that consider skeletal survey mandatory for all such children <24 months of age and support a low threshold to obtain skeletal survey in children as old as 36 months.
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Affiliation(s)
- Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse, Children's Hospital of Colorado, Aurora, CO.
| | - Rachel P Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Maegan S Reynolds
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Riham M Alwan
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
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17
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Abstract
OBJECTIVE Follow-up skeletal surveys (FUSS) are performed frequently in cases of possible physical abuse based on the evidence from small retrospective cohorts. Our objective was to determine the proportion of FUSS that identified new information in a large, multicenter population of children with concerns of physical abuse. METHODS This was a prospective secondary analysis of an observational study of all children <10 years of age (120 months) who underwent evaluation for possible physical abuse by 20 US child abuse teams. This analysis included all children in whom FUSS was recommended and measured rates of FUSS completion, results of FUSS, and the change in perceived likelihood of abuse before and after FUSS. RESULTS Among 2890 children enrolled in the Examining Siblings To Recognize Abuse research network, 2049 underwent skeletal survey and 796 (38.8%) had FUSS. A total of 174 (21.5%) subjects had new information identified by FUSS, including 124 (15.6%) with at least 1 new fracture and 55 (6.9%) with reassuring findings compared with the initial skeletal survey. Among cases with new fractures, the estimated likelihood of abuse increased in 41 (33%) cases, and 51 cases (41%) remained at the maximum likelihood of abuse. CONCLUSIONS FUSS identified new information and affected the perceived likelihood of abuse in a substantial fraction of cases in which it was completed. These data support existing guidelines and, in addition, suggest that FUSS should be considered in cases with lower initial levels of concern for abuse.
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Affiliation(s)
- Nancy S Harper
- Driscoll Children's Hospital, Corpus Christi, TX 78411, USA.
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18
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Maier JK, Hehrmann P, Harper NS, Klump GM, Pressnitzer D, McAlpine D. Adaptive coding is constrained to midline locations in a spatial listening task. J Neurophysiol 2012; 108:1856-68. [PMID: 22773777 DOI: 10.1152/jn.00652.2011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Many neurons adapt their spike output to accommodate the prevailing sensory environment. Although such adaptation is thought to improve coding of relevant stimulus features, the relationship between adaptation at the neural and behavioral levels remains to be established. Here we describe improved discrimination performance for an auditory spatial cue (interaural time differences, ITDs) following adaptation to stimulus statistics. Physiological recordings in the midbrain of anesthetized guinea pigs and measurement of discrimination performance in humans both demonstrate improved coding of the most prevalent ITDs in a distribution, but with highest accuracy maintained for ITDs corresponding to frontal locations, suggesting the existence of a fovea for auditory space. A biologically plausible model accounting for the physiological data suggests that neural tuning is stabilized by inhibition to maintain high discriminability for frontal locations. The data support the notion that adaptive coding in the midbrain is a key element of behaviorally efficient sound localization in dynamic acoustic environments.
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Affiliation(s)
- J K Maier
- UCL Ear Institute, London, United Kingdom
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19
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Hymel KP, Stoiko MA, Herman BE, Combs A, Harper NS, Lowen D, Deye KP, Homa K, Blackman JA. Head injury depth as an indicator of causes and mechanisms. Pediatrics 2010; 125:712-20. [PMID: 20351004 DOI: 10.1542/peds.2009-2133] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children <36 months of age with varying "greatest depths" of acute cranial injury. METHODS Children <36 months of age who were hospitalized with acute head trauma were recruited at multiple sites. Clinical and imaging data were collected, and caregivers underwent scripted interviews. Neurodevelopmental evaluations were completed 6 months after injury. Head trauma causes were categorized independently, and subject groups with varying greatest depths of injury were compared. RESULTS Fifty-four subjects were enrolled at 9 sites. Twenty-seven subjects underwent follow-up neurodevelopmental assessments 6 months after injury. Greatest depth of visible injury was categorized as scalp, skull, or epidural for 20 subjects, subarachnoid or subdural for 13, cortical for 10, and subcortical for 11. Compared with subjects with more-superficial injuries, subjects with subcortical injuries more frequently had been abused (odds ratio [OR]: 35.6; P < .001), more frequently demonstrated inertial injuries (P < .001), more frequently manifested acute respiratory (OR: 43.9; P < .001) and/or circulatory (OR: 60.0; P < .001) compromise, acute encephalopathy (OR: 28.5; P = .003), prolonged impairments of consciousness (OR: 8.4; P = .002), interhemispheric subdural hemorrhage (OR: 10.1; P = .019), and bilateral brain hypoxia, ischemia, or swelling (OR: 241.6; P < .001), and had lower Mental Developmental Index (P = .006) and Gross Motor Quotient (P < .001) scores 6 months after injury. CONCLUSION For children <3 years of age, head injury depth is a useful indicator of injury causes and mechanisms.
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Affiliation(s)
- Kent P Hymel
- Dartmouth-Hitchcock Medical Center, Department of Pediatrics, One Medical Center Dr, Lebanon, NH 03756-0001, USA.
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20
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Abstract
Aboveground plant biomass and litter measurements were made at four intervals between mid-June and late August 1977 on a subarctic salt marsh located at North Point on the southwestern shore of James Bay, Ontario. We sampled six salt marsh zones ranging from a lower intertidal flat dominated by the grass Puccinellia phryganodes to the edge of willow thickets characterized by Juncus balticus.Peak aboveground biomass was reached in nearly all zones by early August, and ranged from 119.3 to 240.4 g dry weight∙m−2. Litter accumulated in all zones except the lower two zones which were subjected to tidal flows. The highest zone where Juncus balticus occurred had the highest litter mass, 572.8 g dry weight∙m−2, while the lowest, 24.7 g∙m−2, occurred in the lowest zone. Estimates of net aerial primary productivity using Smalley's method ranged from 119.3 g∙m−2 in the upper salt marsh to 384.0 g∙m−2 in the zone dominated by Juncus balticus. The mean marsh net aerial primary productivity was 227.7 g∙m−2 which was low compared with other salt marsh data. The 1977 aboveground biomass was lower in 1976, probably as a result of a cooler summer.
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