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Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network.We conducted a cross-sectional study of children10 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.Among 3667 patients with 3721 encounters, 69.4% were3 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.Most children in CAPNET were3 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.

Child labor trafficking is a largely unexplored and unpublished phenomenon in the United States.To 1) characterize the state of the science on child labor trafficking, and 2) identify empirical information regarding risk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.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).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.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.

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.

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.

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.

Objective To replicate the previously published finding that the absence of a history of trauma in a child with obvious traumatic head injuries demonstrates high specificity and high positive predictive value (PPV) for abusive head trauma. Study design This was a secondary analysis of a deidentified, cross-sectional dataset containing prospective data on 346 young children with acute head injury hospitalized for intensive care across 18 sites between 2010 and 2013, to estimate the diagnostic relevance of a caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma inconsistent with the child's gross motor skills. Cases were categorized as definite or not definite abusive head trauma based solely on patients' clinical and radiologic findings. For each presumptive historical “red flag,” we calculated sensitivity, specificity, predictive values, and likelihood ratio (LR) with 95% CI for definite abusive head trauma in all patients and also in cohorts with normal, abnormal, or persistent abnormal neurologic status. Results A caregiver's specific denial of any trauma demonstrated a specificity of 0.90 (95% CI, 0.84-0.94), PPV of 0.81 (95% CI, 0.71-0.88), and a positive LR (LR+) of 4.83 (95% CI, 3.07-7.61) for definite abusive head trauma in all patients. Specificity and LR+ were lowest—not highest—in patients with persistent neurologic abnormalities. The 2 other historical red flags showed similar trends. Conclusions A caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma that is developmentally inconsistent are each highly specific (>0.90) but may provide weaker support than previously reported for a diagnosis of abusive head trauma in patients with persistent neurologic abnormalities.

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 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.

OBJECTIVE: To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN: Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS: In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P < .001 [aOR, 4.1] and P < .001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION: Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians’ implicit bias.

Objective: The goal was to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children Methods: Children 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

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.

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.This was a prospectively planned secondary analysis of an observational study of children10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders.Among 2890 children, 33.9% (980/2890) were6 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.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.

ObjectiveTo 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 designThis was a retrospective secondary analysis of an observational study of 2609 children 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

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 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.

OBJECTIVE: Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse. METHODS: This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 US child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS. RESULTS: Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified. CONCLUSIONS: A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS. Language: en

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.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.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.Applied accurately and consistently, the recently validated, 4-variable CPR could theoretically improve the accuracy of AHT screening in PICU settings.

Theidentification of a skeletal injury may be the first indication of abuse. Estimates of the frequency of fractures in abused children vary from approximately 10% to 50% depending on the population studied, the type of diagnostic imaging used to detect fractures, and the age of the patients seen (Ebbin, Gollub, Stein, & Wilson, 1969; Herndon, 1983; Leventhal, Thomas, Rosenfield, & Markowitz, 1993). Recently, large population-based studies have been used to estimate the incidence of inflicted skeletal trauma. While the majority of fractures are still attributed to falls, child abuse accounts for 12% of fractures in children less than 36 months of age (Leventhal, 2008).

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.

The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.