Emergency Department Triage Chief Complaints Among Children Evaluated for Physical Abuse Concerns

OBJECTIVES

The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services.

METHODS

This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ2, Fisher exact, Kruskal-Wallis).

RESULTS

Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting.

CONCLUSION

Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse.

Specialized programs employing different models of care delivery work collaboratively to address the health care needs of children in foster care

Specialized knowledge and skills applicable to caring for children in foster care include guidelines developed to address this population's special health care needs, cross-system collaboration, and helping families cope with the health impacts of trauma. This paper begins with a review of the special health care needs of children in foster care and relevant guidelines. We discuss different models of health care delivery that can be employed to meet the special health care needs of children in foster care. We then provide examples of two programs employing different models of care that work collaboratively to deliver care to children in foster care in our community.

Use of Telemedicine for Children in Foster Care

Introduction: Telemedicine studies specific to children in foster care are needed, given unique health care needs and barriers. It is important to utilize lessons learned from telemedicine programs deployed by necessity during the COVID-19 emergency. Objectives: Describe telemedicine health assessments for children in foster care performed during the COVID-19 pandemic. Compare medical recommendations resulting from telemedicine and in-person assessments. Methods: After navigating barriers specific to children in foster care including consent issues, we implemented a telemedicine program at our specialty clinic for children in foster care when in-person visits were restricted. Outcomes of telemedicine referrals were tracked. After each visit, physicians were asked to rate ability to express themselves, hear and see patients from 1 (strongly disagree) to 5 (strongly agree) using items from the validated Telehealth Usability Questionnaire. Recommendations for laboratory work, medication, and health services referrals were recorded and compared with 205 patients seen in-person the year prior. Results: From 91 referrals, 83 (91%) children with a mean age of 9 years completed telemedicine visits. Physicians rated receptive and expressive communications more favorably than visual quality. Most telemedicine patients (77%) received a referral for health care services but had significantly lower rates of laboratory work completion, vision referrals, and prescriptions for new medications compared with 205 patients seen in-person. Conclusions: Results suggest that telemedicine was accessible to most patients and highlighted essential in-person components of comprehensive health assessments. Findings could inform ongoing telemedicine applications and advocacy for underserved populations.

Community Resource Connection for Pediatric Caregivers With Unmet Social Needs: A Qualitative Study

OBJECTIVE

Pediatric health systems are increasingly screening caregivers for unmet social needs. However, it remains unclear how best to connect families with unmet needs to available and appropriate community resources. We aimed to explore caregivers' perceived barriers to and facilitators of community resource connection.

METHODS

We conducted semistructured interviews with caregivers of pediatric patients admitted to one inpatient unit of an academic quaternary care children's hospital. All caregivers who screened positive for one or more unmet social needs on a tablet-based screener were invited to participate in an interview. Interviews were recorded, transcribed, and coded by 2 independent coders using content analysis, resolving discrepancies by consensus. Interviews continued until thematic saturation was achieved.

RESULTS

We interviewed 28 of 31 eligible caregivers. Four primary themes emerged. First, caregivers of children with complex chronic conditions felt that competing priorities related to their children's medical care often made it more challenging to establish connection with resources. Second, caregivers cited burdensome application and enrollment processes as a barrier to resource connection. Third, caregivers expressed a preference for geographically tailored, web-based resources, rather than paper resources. Last, caregivers expressed a desire for ongoing longitudinal support in establishing and maintaining connections with community resources after their child's hospital discharge.

CONCLUSION

Pediatric caregivers with unmet social needs reported competing priorities and burdensome application processes as barriers to resource connection. Electronic resources can help caregivers identify locally available services, but longitudinal supports may also be needed to ensure caregivers can establish and maintain linkages with these services.

Using Quality Improvement and Technology to Improve Social Supports for Hospitalized Children

OBJECTIVES

To develop and test the feasibility of a caregiver self-administered social needs screener, a Web-based searchable community resource map, and a process map for implementation of these tools as part of social needs screening and referral on a pediatric inpatient unit.

METHODS

A multidisciplinary team used quality improvement methodology to develop an electronic social needs screener, resource map Web site, and electronic health record enhancements. A process map for implementation of these tools was refined through plan-do-study-act cycles before full implementation. Weekly measures included the number of eligible caregivers screened, prevalence of reported social needs, and use of social work resources.

RESULTS

During the 22-week study period, 147 caregivers were screened and 2 declined to participate. Thirty-four percent of caregivers endorsed ≥1 social need. The most common needs identified were depressive symptoms (23%), food insecurity (19%), and need for assistance with utilities (10%). All participants received information about the resource map, and 99% of caregivers with an identified need met with a social worker during their admission.

CONCLUSIONS

Using quality improvement methodology and technology, the team implemented a new standardized process for addressing social needs on an inpatient unit. This led to identification of social needs in more than one-third of caregivers screened and provision of resource map information to all caregivers. These findings reinforce the importance of standardized assessment of social needs in the pediatric inpatient setting. The role of technology, including resource maps and electronic health record enhancements, was highlighted.

Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics

IMPORTANCE

Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child.

OBJECTIVE

To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020.

EXPOSURES

Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis.

MAIN OUTCOMES AND MEASURES

Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel.

RESULTS

A total of 21 123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp).

CONCLUSIONS AND RELEVANCE

In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.

Utility of screening urinalysis to detect abdominal injuries in suspected victims of child physical abuse

BACKGROUND

Urinalysis, liver enzymes (LE) and lipase are used to screen for abdominal injuries in children with suspected physical abuse (SPA). However, data on the utility of urinalysis is limited.

OBJECTIVES

Describe the prevalence of hematuria in evaluations for SPA. Determine test characteristics of hematuria, LE and lipase to identify kidney and other abdominal injuries among children with SPA.

PARTICIPANTS AND SETTING

Children < 7 years receiving a urinalysis during evaluation for SPA by a hospital child protection team.

METHODS

Demographic, clinical, and laboratory data including presence of hematuria (blood on urine dipstick), elevated LE (> 80 U/L) and elevated lipase (> 100 U/L) were abstracted retrospectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the overall study population and for patients without abdominal symptoms.

RESULTS

Ten percent of patients had hematuria (N = 237). Prevalence of abdominal and kidney injuries was 7 % and 1 % respectively. Of 3 patients with kidney injury, 2 had hematuria and all had elevated LE. Sensitivity (67 %) and NPV (99 %) of hematuria to detect kidney injuries were lower than LE and the same as lipase. Specificity (91 %) and PPV (8%) of hematuria to detect kidney injury were greater than LE and similar to lipase. Sensitivity of hematuria to detect any abdominal injury (50 %) was lower than LE (81 %). Sensitivity of hematuria to detect occult abdominal injury was 0 %.

CONCLUSIONS

Hematuria alone did not lead to detection of kidney injury. Test characteristics of hematuria were largely similar or inferior to LE and lipase.

Long bone fracture characteristics in children with medical conditions linked to bone health

BACKGROUND

Knowledge of fracture characteristics among children with medical conditions affecting bone could help to distinguish medical causes from child abuse.

OBJECTIVE

Characterize long bone fracture morphology among children diagnosed with medical conditions linked to bone health.

PARTICIPANTS AND SETTING

Patients <18 years at a single pediatric hospital diagnosed with a medical condition linked to bone health and ≥1 long bone fracture were studied.

METHODS

This retrospective medical record review categorized underlying medical diagnoses as: metabolic bone disease, genetic disorder of connective tissue, neurologic disorder and other chronic disease. A pediatric radiologist reviewed plain films to determine fracture type and location. Descriptive statistics, as well as logistic regression were used to compare fracture types by clinical characteristics.

RESULTS

Ninety-four patients were included and their diagnoses were genetic connective disorder (19; 20.2 %), metabolic bone disease (16; 17.0 %), neurologic disorder (27; 28.7 %), and other (32; 34.0 %). A total of 216 long bone fractures were sustained; 52.1 % of children had >1 long bone fracture. Of the 216 fractures, 55 (25.5 %) were in children < 1 year, 118 (54.6 %) were associated with known trauma, and 122 (56.5 %) were in non-ambulatory patients. Lower extremity fractures occurred with greatest frequency and most fractures occurred at the mid-diaphysis. Transverse was the most common fracture type in all diagnostic categories. Children with metabolic disorders had highest odds of transverse fracture (COR 3.55, CI 1.45-8.67; neurologic disorders as reference group).

CONCLUSIONS

Diseases affecting bone health can influence fracture morphology. Transverse fractures were most common in bones impacted by disease.

Occult head injuries in infants evaluated for physical abuse

BACKGROUND

Abusive head injuries in infants may be occult but clinically or forensically important. Data conflict regarding yield of neuroimaging in detecting occult head injuries in infants evaluated for physical abuse, with prior studies identifying yields of 4.3-37.3 %.

OBJECTIVES

(1) To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries in infants with concerns for physical abuse and (2) to evaluate risk factors for occult head injuries.

PARTICIPANTS AND SETTING

We conducted a retrospective, stratified, random systematic sample of 529 infants <12 months evaluated for physical abuse at 4 urban children's hospitals in the United States from 2008-2012. Infants with signs or symptoms suggesting head injury or skull fracture on plain radiography (N = 359), and infants without neuroimaging (N = 1) were excluded.

METHODS

Sampling weights were applied to calculate proportions of infants with occult head injuries. We evaluated for associations between hypothesized risk factors (age <6 months, rib or extremity fracture, facial bruising) and occult head injury using chi-square tests.

RESULTS

Of 169 neurologically normal infants evaluated for abuse, occult head injury was identified in 6.5 % (95 % CI: 2.6, 15.8). Infants <6 months were at higher risk (9.7 %; 95 % CI: 3.6, 23.3) than infants 6-12 months (1.0 %; 95 % CI: 1.3, 20.2). Rib fracture, extremity fracture and facial bruising were not associated with occult head injury.

CONCLUSIONS

Occult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants <6 months. Clinicians should have a low threshold to obtain neuroimaging in young infants with concern for abuse.

Are negative/unrealistic parent descriptors of infant attributes associated with physical abuse?

Parents' perceptions of child behavior influence their responses to the child and may be important predictors of physical abuse. We examined whether infants 12 months of age or younger who were described with negative or developmentally unrealistic words were more likely than other infants to have been physically abused. As part of a prospective observational multicenter study investigating bruising and familial psychosocial characteristics, parents were asked to (1) describe their child's personality, and (2) list three words to describe their child. Four independent raters coded parent responses using a qualitative content analysis, identifying descriptors of infants and classifying each as positive, neutral, or negative/unrealistic. A medical expert panel, blinded to the psychosocial data, separately categorized each case as abuse or accident. We then analyzed the potential association between negative/unrealistic descriptors and abusive injury. Of 185 children enrolled, 147 cases (79%) were categorized as accident and 38 (21%) as abuse. Parents used at least one negative/unrealistic descriptor in 35/185 cases (19%), while the remaining 150 cases (81%) included only positive or neutral descriptors. Of the infants described with negative/unrealistic words, 60% were abused, compared to 11% of those described with positive or neutral words (p < .0001; age group-adjusted OR = 9.95; 95% confidence interval [3.98, 24.90]). Though limited by sample-size, this pilot study informs future work to create a screening tool utilizing negative/unrealistic descriptors in combination with other predictive factors to identify infants at high risk for physical child abuse.

Missed Medical Appointments and Disease Control in Children With Type 1 Diabetes

The need exists to identify children with type 1 diabetes who are at risk for poor outcomes, and we hypothesized that missed appointments could be a useful indicator. We aimed to describe the frequency of missed medical appointments in children with type 1 diabetes and evaluate the relationship between missed appointments and poor disease control. Medical records of 1,002 children aged 0-17 years with type 1 diabetes and two or more scheduled appointments during a 43-month period were reviewed. Sixty-eight percent of patients missed no appointments, 17% missed one appointment, and 15% missed two or more appointments. Compared with patients who missed no appointments, patients who missed two or more appointments were three times more likely to have a diabetic ketoacidosis episode and three times more likely to have a hemoglobin A1c level equal to or greater than 8.5%. They were also more likely to be a member of a racial/ethnic minority group and be publicly insured. Missed appointments may be an important indicator of poor treatment adherence, requiring targeted interventions.

Characteristics of Children Reported to Child Protective Services for Medical Neglect

OBJECTIVES

Medical neglect can have serious consequences. There is little evidence base to guide medical neglect management and research. Our objective was to describe a group of children reported to child protective services (CPS) for medical neglect to define this population as well as identify prevention and intervention approaches.

METHODS

This was a retrospective descriptive study of all patients at a pediatric hospital reported to CPS for medical neglect over a 6-year period. Data about health, health care, CPS involvement, and social history were obtained through medical record review.

RESULTS

Of the 154 patients reported for medical neglect, 140 (91%) had chronic illness. The most common diagnoses were type 1 diabetes, organ transplantation, and prematurity-related conditions. Most patients (83%) were black or Hispanic and 90% were publically insured. More than half of patients (54%) had >1 CPS report during the study period. Almost all patients (88%) returned to the hospital for care subsequent to the medical neglect report. Risk factors for child maltreatment, family stressors in the year preceding the report, and practical barriers to care were documented in more than two-thirds of patients.

CONCLUSIONS

Overall, children reported for medical neglect have serious chronic medical conditions. There is need and opportunity for improved interventions. Avenues for future study include interventions tailored to the underlying diagnosis, racial/ethnic disparities, effectiveness of CPS interventions, and targeted prevention for at-risk families with medically complex children.

Medical Management and Trauma-Informed Care for Children in Foster Care

Children enter foster care with a myriad of exposures and experiences, which can threaten their physical and mental health and development. Expanding evidence and evolving guidelines have helped to shape the care of these children over the past two decades. These guidelines address initial health screening, comprehensive medical evaluations, and follow-up care. Information exchange, attention to exposures, and consideration of how the adversities, which lead to foster placement, can impact health is crucial. These children should be examined with a trauma lens, so that the child, caregiver, and community supports can be assisted to view their physical and behavioral health from the perspective of what we now understand about the impact of toxic stress. Health care providers can impact the health of foster children by screening for the negative health consequences of trauma, advocating for trauma-informed services, and providing trauma-informed anticipatory guidance to foster parents. By taking an organized and comprehensive approach, the health care provider can best attend to the needs of this vulnerable population.

Physical Health Problems and Barriers to Optimal Health Care Among Children in Foster Care

Children and adolescents in foster care placement represent a unique population with special health care needs, often resulting from pre-placement early adversity and neglected, unaddressed health care needs. High rates of all health problems, including acute and/or chronic physical, mental, and developmental issues prevail. Disparities in health status and access to health care are observed. This article summarizes the physical health problems of children in foster care, who are predisposed to poor health outcomes when complex care needs are unaddressed. Despite recognition of the significant burden of health care need among this unique population, barriers to effective and optimal health care delivery remain. Legislative solutions to overcome obstacles to health care delivery for children in foster care are discussed.

Medical neglect

Medical neglect occurs when children are harmed or placed at significant risk of harm by gaps in their medical care. This is most likely to occur and to be recognized when families lack resources, commonly due to poverty, and when medical demands are high, such as with complex, severe, and chronic illness. A systematic evaluation of the probabilities for harm from gaps in care versus benefits from improved care will define medical neglect. A broad consideration of child, family, community, and medical system contributions to identified gaps will guide management. Special circumstances, such as lapsed immunizations, unremitting obesity, and medically motivated alterations in care, are often challenging for medical providers. Guidance for these specific situations is available from the American Academy of Pediatrics, and from the medical literature.

Sexual abuse

Child sexual abuse is a common pediatric problem that concerns all pediatric health care providers. Management of child sexual abuse is multifaceted and multidisciplinary. Specialized health providers can provide consultation, but this availability does not minimize the role of the referring physician who often has ongoing contact with the family. Physicians are mandated to report cases of suspected or confirmed sexual abuse. In the majority of cases, a child’s statement about sexual abuse is the strongest evidence that abuse has occurred. Physical examination is normal in the majority of sexual abuse victims. Accurate, evidence-based interpretation of physical and laboratory findings is essential. Normal examinations, normal variants, and findings indicative of sexual contact must be differentiated. Forensic evidence collection and prophylactic treatments may be indicated when patients present within 72 hours of an abusive episode, and patients should be triaged accordingly. Potentially negative psychosocial outcomes should be addressed for patients and their families on initial evaluation and follow-up.

MicroRNAs: biogenesis and molecular functions

Small regulatory RNAs are essential and ubiquitous riboregulators that are the key mediators of RNA interference (RNAi). They include microRNAs (miRNAs) and short-interfering RNAs (siRNAs), classes of approximately 22 nucleotide RNAs. miRNAs and siRNAs bind to Argonaute proteins and form effector complexes that regulate gene expression; in animals, this regulation occurs primarily at the post-transcriptional level. In this review, we will discuss our current understanding of how miRNA and siRNAs are generated and how they function to silence gene expression, focusing on animal and, in particular, mammalian miRNAs.

Prevalence of positive tuberculin skin tests in foreign-born children

AIMS

To evaluate the prevalence of positive tuberculin skin tests (TST) in internationally adopted and immigrant children. To identify risk factors for positive TST in these populations.

METHODS

The study was a retrospective medical record review in a tertiary care pediatric hospital. All children evaluated at the International Adoption and Immigrant Health Clinic of CHU Sainte-Justine in Montreal, Canada, between 01-01-1998 and 31-12-2001 were included. Demographic and anthropometrical data, BCG vaccination, TST, chest X-ray results and treatment were extracted from the medical records of the patients and analyzed. Positive TST was defined as induration = 10 mm, 48 to 72 hours after injection of five tuberculin units of purified protein derivate.

RESULTS

Our population included 670 children: 112 immigrants and 558 adoptees. Median age was 6.9 years for immigrants and 1.1 years for adopted children. Overall incidence of positive TST was 12.2% in our cohort: 31% in the immigrant and 8% in the adopted children groups. There was one case of active tuberculosis. Older age on arrival in Canada and BCG vaccination were identified as risk factors for positive TST in our multivariate model. For each one-year increase in age on arrival in Canada, there was a 1.2 times greater risk for positive TST.

CONCLUSIONS

Latent tuberculosis is a frequent problem in foreign-born children. The higher incidence in immigrant children can be explained by older age on arrival.