Fatal child neglect.

Child neglect results from either acts of omission or of commission. Fatalities from neglect account for 30% to 40% of deaths caused by child maltreatment. Deaths may occur from failure to provide the basic needs of infancy such as food or medical care. Medical care may also be withheld because of parental religious beliefs. Inadequate supervision may contribute to a child's injury or death through adverse events involving drowning, fires, and firearms. Recognizing the factors contributing to a child's death is facilitated by the action of multidisciplinary child death review teams. As with other forms of child maltreatment, prevention and early intervention strategies are needed to minimize the risk of injury and death to children.

The clinical utility of the rectal-skin temperature difference in the assessment of young infants.

OBJECTIVE: Previous studies have suggested that the degree of difference between rectal temperature and peripheral skin temperature [rectal-skin temperature difference (RSTD)] is predictive of serious illness in young infants. The authors sought to determine the clinical utility of the RSTD in the outpatient evaluation of infants up to 2 months of age for serious infectious illness (SII). METHODS: Simultaneous rectal and skin (anterior mid-lower leg) temperatures were recorded for all infants < or = 2 months of age seen in the ED over a one-year period. The physician's clinical assessment, rectal temperature, skin temperature, laboratory results, and final diagnoses were also recorded. The RSTD (rectal temperature - skin temperature) was calculated for each infant. Final diagnoses were recorded and classified as SII or nonserious illness (NSI). Mean RSTD for each group was calculated and data were analyzed by the Wilcoxon rank sum test and multivariate regression model. RESULTS: A total of 601 infants [mean age of 28 days (range 2-65 days)] were enrolled. Nine percent (57 of 601) of infants had SII. Forty percent (23 of 57) of infants with SII were febrile, and 60% (34 of 57) were afebrile. The mean RSTD of febrile infants with SII was 5.8 +/- 1.7 degrees C (range 3.2-9.7 degrees C) and 5.3 +/- 1.4 degrees C (range 3.0-7.6 degrees C) for febrile infants with NSI. The mean RSTD of afebrile infants with SII was 4.8 +/- 1.8 degrees C (range 2-12.5 degrees C) and 4.4 +/- 1.5 degrees C (range 0.04-10.9 degrees C) for afebrile infants with NSI. The RSTD was not associated with SII in either febrile or afebrile infants (p > 0.05, Wilcoxon rank sum test). A multivariate logistic regression model of age, rectal temperature, and RSTD suggested an independent association of rectal temperature with SII (p < 0.0001), but none between age or RSTD and SII (p > 0.05). CONCLUSION: Once the rectal temperature is known, the RSTD is not a clinically useful test in the evaluation of young infants for serious infectious illness.

Documentation of child physical abuse: how far have we come?

OBJECTIVES: To determine the effects of increased physician training and a structured clinical form on physician documentation of child physical abuse. DESIGN: Retrospective chart review. PARTICIPANTS: Children evaluated in the pediatric emergency department in 1980 and 1995 who were given the diagnosis of physical abuse. MEASUREMENTS: The unstructured pediatric emergency department form and the structured child abuse reporting form were reviewed for documentation of 20 items including history, physical examination, diagnostic procedures, and disposition. Data documented in 1980 were compared with that in 1995. RESULTS: The only significant differences between 1980 and 1995 concerning documentation on the unstructured pediatric emergency department form were better recording in the latter year of Child Protective Services involvement and case disposition. Half or more of the records omitted documentation of at least one of the following: witnesses to injury, past injuries, description of size and/or color of injuries, illustration, and a genital exam. None of the records contained a developmental history. Significantly fewer skeletal surveys were obtained in 1995, although notation of the results was similar to 1980. For both years, the structured child abuse reporting form improved documentation of only two items: time of arrival to the pediatric emergency department and illustrations of injuries. CONCLUSIONS: Little improvement in physician documentation of child physical abuse was noted between 1980 and 1995 despite increased efforts to educate housestaff in the evaluation of child abuse during this time period. Although a structured form prompted physicians to document dates and times and to illustrate physical injuries on the diagram provided, it did not significantly improve documentation of other items.

Upper airway obstruction after pharyngeal flap surgery.

Upper airway obstruction after superiorly based pharyngeal flap procedures for the treatment of velopharyngeal insufficiency is described in this series of 32 flaps performed in 29 patients at our institution between 1979 and 1993. A high incidence of upper airway obstruction symptoms (38%) occurred in the early postoperative period but resolved in all but 2 patients within 5 months. None of the patients required flap revision or other procedures for relief of upper airway obstruction. Velopharyngeal insufficiency was improved or completely eliminated in 87% of patients. Significant residual velopharyngeal insufficiency in 13% of patients was treated successfully in all flap revision cases. Race, gender, age at closure, and associated craniofacial anomalies did not correlate with upper airway obstruction or with the efficacy of treatment for velopharyngeal insufficiency. However, patients with transient postoperative upper airway obstruction were only half as likely to suffer residual postoperative velopharyngeal insufficiency. The inverse relationship between velopharyngeal insufficiency and upper airway obstruction (p = .008) suggests that the surgeon may sometimes need to accept some transient upper airway obstruction to achieve correction of velopharyngeal insufficiency.

Microdontia with severe microcephaly and short stature in two brothers: osteodysplastic primordial dwarfism with dental findings.

Two brothers from a black family had microcephaly, short stature, and generalized microdontia. Endocrine and chromosome studies were normal, and mild skeletal manifestations were present. The patients may represent a distinct dental-skeletal dysplasia, possibly osteodysplastic primordial dwarfism type II. Attention to dental manifestations in similar cases may be useful for classification.

Pediatric abuse. New patterns of injury.

The spectrum of abusive symptomatology has continued to expand since the initial report of the battered child syndrome. Many of these abused children present to the ED without a history of trauma. The ED physician must be aware of the range of clinical signs and symptoms to recognize and treat these children.

The effects of bundling on infant temperature.

OBJECTIVE: To determine whether bundling elevates rectal and/or skin temperature of young infants. DESIGN: Randomized, prospective study stratified by age. SETTING: Clinical Studies Center at a teaching hospital in Los Angeles. PATIENTS: Sixty-four well, full-term infants (ages 11 to 95 days). INTERVENTIONS: Control infants (n = 28) were dressed in a disposable diaper and terry coveralls. Bundled infants (n = 36) were dressed as control infants, plus a cap, a receiving blanket, and a thermal blanket. All infants were monitored in an open crib (room temperature 72 degrees to 75 degrees F). Rectal and skin (anterior mid-lower leg) temperatures and infant states were measured at 5-minute intervals from time 0 to 60 minutes and at 62 and 65 minutes. RESULTS: The mean skin temperature of bundled infants increased by 2.67 degrees C/hr; mean rectal temperature increased by 0.06 degrees C/hr. The mean skin temperature of nonbundled infants increased by 1.5 degrees C/hr; mean rectal temperature decreased by less than 0.01 degree C/hr. Comparing bundled infants to nonbundled controls, there was a significant rise in skin temperature (P = .0001) but not in rectal temperature (P > .05, Wilcoxon rank sum test). The study had a power > 98% to detect a rise of .5 degrees C in rectal temperature over 60 minutes. The 95% confidence interval for the change in rectal temperature in bundled infants was -0.03 to +0.15 degrees C. CONCLUSIONS: Bundling a healthy infant in a temperate external environment causes an increase in skin temperature, but not in rectal temperature. Elevated rectal temperatures should therefore, rarely if every be attributed to bundling.

Parental recall after a visit to the emergency department.

Using exit interviews, we determined parental recall of their child's diagnosis, treatment, and follow-up instructions after a visit to the emergency department (ED). Over 2 weeks, 159 parents were interviewed. Exclusion criteria were: parental language other than Spanish or English, admission, trauma, child abuse, or a primary psychiatric diagnosis. Neither language nor parental satisfaction with communication (reported in 93%) was associated with ability to state the diagnosis correctly (P = NS). Seventy-five percent (88 of 117) of parents of children given a single diagnosis stated it correctly; 55% (23 of 42) of parents of children given multiple diagnoses were able to correctly state them all (P = 0.013). If a single medication was prescribed, 30% (20 of 67) of parents knew its name, while only 13% (four of 31) knew all names of multiple medications (P = 0.070). Of those parents given a single medication, 51% (34 of 67) knew how to administer it, while only 10% (three of 31) knew how to administer multiple medications (P < 0.001). Similarly, 58% (46 of 79) of parents given a single appointment knew the date and place of their child's follow-up, while only 16% (three of 19) given multiple appointments knew all dates and locations (P = 0.001). These data suggest that despite high parental satisfaction with communication, many parents cannot fully recall their child's diagnosis, treatment, and follow-up--especially when multiple diagnoses, medications, or appointments are given.

Testing the sexually abused child for the HIV antibody: issues for the social worker.

The frequency of HIV transmission to children and adolescents through sexual abuse is unknown. Because the incidences of HIV infection and of reported sexual abuse are both increasing, the transmission of HIV to children through sexual abuse may also be increasing. Social workers may have expanding roles in the decision-making process for testing and subsequent management of children infected with HIV through sexual abuse. This article discusses the benefits of identifying children who have been infected with HIV through sexual abuse and reviews guidelines for testing. Social workers can contribute to test decision making in instances when perinatal HIV transmission is a possibility, when it may be possible to test the assailant, and when parents or legal guardians insist on testing the child. Other issues discussed include family education and coping, physical education and support, social casework and research with pedophiles, and service needs for care and follow-up of children found to be HIV infected as a result of sexual abuse.

Situational and sociodemographic characteristics of children infected with human immunodeficiency virus from pediatric sexual abuse.

This study assessed the situational and sociodemographic characteristics of children infected with human immunodeficiency virus (HIV) from pediatric sexual abuse. A letter of inquiry was sent to 2147 professionals across health and social service disciplines involved with child abuse assessment, treatment, and prevention. Respondents working in programs where HIV antibody testing of abuse victims occurs and who had identified HIV infection in one or more abused children were sent a survey to assess the demographics of victims, the family/living situation where abuse occurred, alternative risks for HIV infection, bases for diagnosis of sexual abuse and for HIV antibody testing, and profiles of the perpetrator and type of abuse. Of 5622 estimated HIV antibody tests conducted during 113,198 sex abuse assessments, 28 children were infected with HIV and lacked any alternative transmission route to that of sexual abuse. A total of 41 HIV-infected children with a history of sexual abuse were identified. Thirteen cases had alternative risk factors and were excluded from analysis. Sixty-four percent of the 28 victims with sexual abuse as the sole risk factor were female and 71% were African-American. The mean age was 9 years. Coinfection with another sexually transmitted disease (STD) occurred in 9 (33%) cases. Sexual abuse was diagnosed on the basis of a victim disclosure in 21 (75%) cases. The basis for HIV antibody testing was physical findings suggestive of HIV infection in 9 (32%) cases, HIV-seropositive or high-risk perpetrator in 6 (21%) and 2 (7%) cases, respectively, and the presence of another STD in the victim in 4 (14%) cases. Perpetrators were a child's parent in 10 (42%) cases and another relative in 6 (25%) cases.(ABSTRACT TRUNCATED AT 250 WORDS)