Faculty Bibliography

Over the past decade, there have been widespread efforts to raise awareness about maltreatment of children. Pediatric providers have received education about factors that make a child more vulnerable to being abused and neglected. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population at increased risk for maltreatment. This report updates the 2007 American Academy of Pediatrics clinical report "Maltreatment of Children With Disabilities." Since 2007, new information has expanded our understanding of the incidence of abuse in this vulnerable population. There is now information about which children with disabilities are at greatest risk for maltreatment because not all disabling conditions confer the same risks of abuse or neglect. This updated report will serve as a resource for pediatricians and others who care for children with disabilities and offers guidance on risks for subpopulations of children with disabilities who are at particularly high risk of abuse and neglect. The report will also discuss ways in which the medical home can aid in early identification and intervene when abuse and neglect are suspected. It will also describe community resources and preventive strategies that may reduce the risk of abuse and neglect.

OBJECTIVES/OBJECTIVE:To determine diagnoses and image features that are associated with difficult prepubescent female genital image interpretations. DESIGN/METHODS:and Setting. This was a mixed methods study conducted at a tertiary care pediatric centre using images from a previously developed education platform. PARTICIPANTS/METHODS:These included 107 medical students, residents, fellows and attendings who interpreted 158 cases to derive case difficulty estimates. INTERVENTIONS/METHODS:This was a planned secondary analysis of participant performance data obtained from a prospective multi-center cross-sectional study. An expert panel also performed a descriptive review of images with the highest frequency of diagnostic error. MAIN OUTCOME MEASURES/METHODS:We derived the proportion of participants that interpreted an image correctly and features that were common in images with the most frequent diagnostic error. RESULTS:We obtained 16,906 image interpretations. The mean proportion correct scores for each diagnosis were as follows: normal/normal variants 0.84 (95% CI 0.82, 0.87); infectious/dermatology pathology 0.59 (95% CI 0.45, 0.73); anatomic pathology 0.61 (95% CI 0.41, 0.81); and, traumatic pathology 0.64 (95% CI 0.49, 0.79). The mean proportion correct scores varied by diagnosis, p < 0.001. The descriptive review demonstrated that poor image quality, infant genitalia, normal variant anatomy, external material (cream) in genital area, and nonspecific erythema were common features in images with lower accuracy scores. CONCLUSIONS:A quantitative and qualitative examination of prepubescent female genital examination image interpretations provided insight into diagnostic challenges for this complex examination. These data can be used to inform the design of teaching interventions to improve skill in this area.

Sexual violence against children is a gross violation of children's rights during their formative years and will likely interfere with their developmental trajectory and long-term quality of life. As a result, this form of violence includes commercial sexual exploitation of children, sexual abuse, child marriages, and female genital mutilation. The evidence shows that violence prevention is worth the investment; however, prioritizing this agenda to ensure funding through government spending remains low. Despite funding realities, research and advocacy efforts need to continue, with a focus on promoting effective practices for mitigation.

Abusive suffocation with foreign bodies is an uncommon form of child abuse. We present the case of a 2-month-old infant with colic who was forcibly suffocated with a baby wipe by a female babysitter. He presented to the emergency department in respiratory distress, and the foreign body was removed in the operating room by otorhinolaryngology. He was found to have intraoral lacerations and a left diaphyseal humeral fracture. To our knowledge, there is only 1 other collection of case reports of abusive suffocation with baby wipes. This case highlights the importance of considering abuse in cases of oral injury and foreign body aspiration in pediatric patients.

BACKGROUND:Correct interpretation of the prepubescent female genital examination is a critical skill; however, physician skill in this area is limited. OBJECTIVE:To complement the bedside learning of this examination, we developed a learning platform for the visual diagnosis of the prepubescent female genital examination and examined the amount and rate of skill acquisition. PARTICIPANTS AND SETTING/METHODS:Medical students, residents, and fellows and attendings participated in an on-line learning platform. METHODS:This was a multicenter prospective cross-sectional study. Study participants deliberately practiced 158 prepubescent female genital examination cases hosted on a computer-based learning and assessment platform. Participants assigned the case normal or abnormal; if abnormal, they identified the location of the abnormality and the specific diagnosis. Participants received feedback after every case. RESULTS:We enrolled 107 participants (26 students, 31 residents, 24 fellows and 26 attendings). Accuracy (95 % CI) increased by 10.3 % (7.8, 12.8), Cohen's d-effect size of 1.17 (1.14, 1.19). The change in specificity was +16.8 (14.1, 19.5) and sensitivity +2.4 (-0.9, 5.6). It took a mean (SD) 46.3 (32.2) minutes to complete cases. There was no difference between learner types with respect to initial (p = 0.2) or final accuracy (p = 0.4) scores. CONCLUSIONS:This study's learning intervention led to effective and feasible skill improvement. However, while participants improved significantly with normal cases, which has relevance in reducing unnecessary referrals to child protection teams, learning gains were not as evident in abnormal cases. All levels of learners demonstrated a similar performance, emphasizing the need for this education even among experienced clinicians.

Pediatricians provide continuous medical care and anticipatory guidance for children who have been reported to state child protection agencies, including tribal child protection agencies, because of suspected child maltreatment. Because families may continue their relationships with their pediatricians after these reports, these primary care providers are in a unique position to recognize and manage the physical, developmental, academic, and emotional consequences of maltreatment and exposure to childhood adversity. Substantial information is available to optimize follow-up medical care of maltreated children. This new clinical report will provide guidance to pediatricians about how they can best oversee and foster the optimal physical health, growth, and development of children who have been maltreated and remain in the care of their biological family or are returned to their care by Child Protective Services agencies. The report describes the pediatrician's role in helping to strengthen families' and caregivers' capabilities and competencies and in promoting and maximizing high-quality services for their families in their community. Pediatricians should refer to other reports and policies from the American Academy of Pediatrics for more information about the emotional and behavioral consequences of child maltreatment and the treatment of these consequences.

PURPOSE/OBJECTIVE:Estimate the prevalence of child sex trafficking (CST) among patients seeking care in multiple healthcare settings; evaluate a short screening tool to identify victims in a healthcare setting. METHODS:This cross-sectional observational study involved patients from 16 sites throughout the U.S.: five pediatric emergency departments, six child advocacy centers, and five teen clinics. Participants included English-speaking youth ages 11-17years. For emergency department sites, inclusion criteria included a chief complaint of sexual violence. Data on several domains were gathered through self-report questionnaires and examiner interview. Main outcomes included prevalence of CST among eligible youth; sensitivity, specificity, positive/negative predictive values, and positive/negative likelihood ratios for a CST screening tool. RESULTS:Eight hundred and ten participants included 91 (11.52%) youth from emergency departments, 395 (48.8%) from child advocacy centers, and 324 (40.0%) from teen clinics. Overall prevalence of CST was 11.1%: 13.2% among emergency department patients, 6.3% among child advocacy center patients, and 16.4% among teen clinic patients, respectively. The screen had a sensitivity, specificity, and positive likelihood ratio of 84.44% (75.28, 91.23), 57.50% (53.80, 61.11), and 1.99% (1.76, 2.25), respectively. CONCLUSIONS:This study demonstrates a significant rate of CST among patients presenting to emergency departments (for sexual violence complaints), child advocacy centers, and teen clinics. A six-item screen showed relatively good sensitivity and moderate specificity. Negative predictive value was high. Intervention for a "positive" screen may identify victims and help prevent high-risk youth from becoming victimized. This is one of the first CST screening tools specifically developed and evaluated in the healthcare setting.

High-quality home-visiting services for infants and young children can improve family relationships, advance school readiness, reduce child maltreatment, improve maternal-infant health outcomes, and increase family economic self-sufficiency. The American Academy of Pediatrics supports unwavering federal funding of state home-visiting initiatives, the expansion of evidence-based programs, and a robust, coordinated national evaluation designed to confirm best practices and cost-efficiency. Community home visiting is most effective as a component of a comprehensive early childhood system that actively includes and enhances a family-centered medical home.

OBJECTIVES: As part of a large randomized controlled trial, the authors assessed the impact of 2 early primary care parenting interventions-the Video Interaction Project (VIP) and Building Blocks (BB)-on the use of physical punishment among low-income parents of toddlers. They also determined whether the impact was mediated through increases in responsive parenting and decreases in maternal psychosocial risk. METHODS: Four hundred thirty-eight mother-child dyads (161 VIP, 113 BB, 164 Control) were assessed when the children were 14 and/or 24 months old. Mothers were asked about their use of physical punishment and their responsive parenting behaviors, depressive symptoms, and parenting stress. RESULTS: The VIP was associated with lower physical punishment scores at 24 months, as compared to BB and controls. In addition, fewer VIP parents reported ever using physical punishment as a disciplinary strategy. Significant indirect effects were found for both responsive parenting and maternal psychosocial risk, indicating that the VIP affects these behaviors and risk factors, and that this is an important pathway through which the VIP affects the parents' use of physical punishment. CONCLUSION: The results support the efficacy of the VIP and the role of pediatric primary care, in reducing the use of physical punishment among low-income families by enhancing parent-child relationships. In this way, the findings support the potential of the VIP to improve developmental outcomes for at-risk children.