Faculty Bibliography

Child maltreatment (CM) is recognized as a major public health concern, and an important number of children suffer injuries related to abuse and neglect which result in death.
Objective(s): We sought to identify risk factors for CM fatalities among hospitalized children that can provide clinicians with information to recognize children at-risk and reduce further death.
Patient(s): This study included cases from the Kids' Inpatient Database (KID) with diagnosis codes related to CM who were <5y and were not transferred to another facility.
Method(s): Potential demographic and clinical risk factors were identified and compared with child fatality using bivariate and multivariate analysis. To assess how cases coded specifically for maltreatment differed from similar cases that only suggested maltreatment, a reduced model multivariable logistic regression for fatality was created.
Result(s): We found 22,061 children younger than 5 years who had inpatient diagnoses coded in their medical record for CM. Most demographic variables (age, race, and gender) were not significantly associated with fatality, whereas clinical variables (asphyxiation and traumatic injuries) were significantly associated with fatality. Controlling for significant risk factors, those with diagnoses specific for CM had almost twice the odds of dying (OR= 1.767; 95% CI: 1.330-2.348).
Conclusion(s): In the US, the age, race, and gender of the patients are not important factors when considering CM fatality for hospitalized children <5y. Important factors are the types of injuries the child has endured and whether or not the inpatient clinician has made a diagnosis of CM

BACKGROUND AND OBJECTIVES/OBJECTIVE:Child maltreatment (CM) is recognized as a major public health concern, and an important number of children suffer injuries related to abuse and neglect that result in death. We sought to identify risk factors for CM fatalities among hospitalized children that can provide clinicians with information to recognize at-risk children and reduce further death. METHODS:In this study, we included cases from the 2012 Kids' Inpatient Database with diagnosis codes related to CM who were <5 years of age and were not transferred to another facility. Potential demographic and clinical risk factors were identified and compared to child fatality in the hospital by using bivariate and multivariate analyses. To assess how cases coded specifically for maltreatment differed from similar cases that only suggested maltreatment, a reduced-model multivariable logistic regression for fatality was created. RESULTS:We found 10 825 children <5 years who had inpatient diagnoses coded in their medical record for CM. Most demographic variables (age, race, and sex) were not significantly associated with fatality, whereas clinical variables (transferring in, drowning, ingestions, and burns) were significantly associated with fatality. There were regional differences on the basis of hospital location as well as significantly more chronic conditions, procedure charges, and longer lengths of stay among children who died. Controlling for significant risk factors, those with diagnoses specific for physical abuse had ∼3 times the odds of dying (odds ratio = 2.797; 95% confidence interval: 1.941-4.031). CONCLUSIONS:In this study, although infancy and decreased income were associated with increased risk for fatality, more important factors were the types of injuries the child endured and whether the inpatient clinician had identified specific injuries indicating physical abuse.

Child abuse is a common and morbid condition that is frequently identified in the emergency department, but emergency departments far outnumber specialized child abuse pediatricians. The small size and slow growth of child abuse as a specialty requires innovative approaches to ensure that specialized services are available to all children who may have been abused. This review covers the history and core concepts of telemedicine in child abuse pediatrics, highlighting services including live patient visits, advice and consultation, and retrospective peer review. We describe a deliberate approach to establishing a telemedicine program. Training and practice help establish new competencies in this form of medicine. Evaluation and sound business planning lead to sustainable and positive change. We also discuss challenges unique to child abuse telemedicine including confidentiality, security, provider engagement, and specialized training. Child abuse is a common and pervasive problem whereas child abuse pediatricians are both few and far between. Telemedicine may provide a solution to problems of availability and distribution within our specialty.

Purpose/UNASSIGNED:Pediatric fingertip injuries are most commonly reported in the setting of an accidental occurrence. The purpose of this study was to determine whether there is an association of child abuse and neglect with pediatric fingertip injuries. Methods/UNASSIGNED:The New York Statewide Planning and Research Cooperative System (2004 to 2013) administrative database was used to identify children aged 0 to 12 years who presented in the inpatient or outpatient (emergency department or ambulatory surgery) setting. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify fingertip injuries (amputation, avulsion, or crushed finger) and abuse. Cohort demographics of children presenting with fingertip injuries were described. We analyzed the association between fingertip injuries and child abuse using multivariable logistic regression, with variables for insurance status, race, ethnicity, sex, and behavioral risks including depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism. Results/UNASSIGNED:Of the 4,870,299 children aged 0 to 12 years in the cohort, 79,108 patients (1.62%) during the study period (2004 to 2013) presented with fingertip injuries. Of those with a fingertip injury, 0.27% (n = 216) presented either at that visit or in other visits with a code for child abuse, compared with 0.22% of pediatric patients without a fingertip injury (n = 10,483). In an adjusted analysis, the odds of a fingertip injury were 23% higher (odds ratio [OR] = 1.23; 95% confidence interval [CI], 1.07-1.41) for children who had been abused, compared with those who had not. Patients were more likely to present with fingertip injuries if they had ever had Medicaid insurance (OR = 1.40; 95% CI, 1.37-1.42) or had a behavioral risk factor (OR = 1.35; 95% CI, 1.30-1.40). Conclusions/UNASSIGNED:Patients presenting with abuse are significantly more likely to have fingertip injuries during childhood compared with those without recorded abuse, which suggests that these injuries may be ones of abuse or neglect. Medicaid insurance, white race, and behavioral diagnoses of depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism were also associated with increased odds of presenting with fingertip injuries. Type of study/level of evidence/UNASSIGNED:Prognostic III.

When a healthy infant dies suddenly and unexpectedly, it is critical to correctly determine if the death was caused by child abuse or neglect. Sudden unexpected infant deaths should be comprehensively investigated, ancillary tests and forensic procedures should be used to more-accurately identify the cause of death, and parents deserve to be approached in a nonaccusatory manner during the investigation. Missing a child abuse death can place other children at risk, and inappropriately approaching a sleep-related death as maltreatment can result in inappropriate criminal and protective services investigations. Communities can learn from these deaths by using multidisciplinary child death reviews. Pediatricians can support families during investigation, advocate for and support state policies that require autopsies and scene investigation, and advocate for establishing comprehensive and fully funded child death investigation and reviews at the local and state levels. Additional funding is also needed for research to advance our ability to prevent these deaths.

Unexplained childhood fracture(s) warrant consideration of physical abuse and osteogenesis imperfecta (OI). Genetic OI testing may identify "variants of unknown significance (VUS)." Interpretation of VUS in context of potential abuse may have protective, criminal, and medical impacts. This case series explores practices regarding clinicians' interpretation of VUS during child abuse evaluations. Variability was noted regarding factors considered for interpreting clinical significance. Based on these cases, recommendations for careful and thorough evaluation are detailed, including proposed use of a limited follow-up skeletal survey in 3 months, as a consideration to assess healing of prior fractures and to look for any additional injuries.