Identifying Children at Risk for Maltreatment Using Emergency Medical Services' Data: An Exploratory Study.

The objective of this study was to use natural language processing to query Emergency Medical Services (EMS) electronic health records (EHRs) to identify variables associated with child maltreatment. We hypothesized the variables identified would show an association between the Emergency Medical Services encounter and risk of a children maltreatment report. This study is a retrospective cohort study of children with an EMS encounter from 1/1/11-12/31/18. NLP of EMS EHRs was conducted to generate single words, bigrams and trigrams. Clinically plausible risk factors for child maltreatment were established, where presence of the word(s) indicated presence of the hypothesized risk factor. The EMS encounters were probabilistically linked to child maltreatment reports. Univariable associations were assessed, and a multivariable logistic regression was conducted to determine a final set of predictors. 11 variables showed an association in the multivariable modeling. Sexual, abuse, chronic condition, developmental delay, unconscious on arrival, criminal activity/police, ingestion/inhalation/exposure, and <2 years old showed positive associations with child maltreatment reports. Refusal and DOA/PEA/asystole held negative associations. This study demonstrated that through EMS EHRs, risk factors for child maltreatment can be identified. A future direction of this work include developing a tool that screens EMS EHRs for households at risk for maltreatment.

Providers' Ability to Identify Sentinel Injuries Concerning for Physical Abuse in Infants.

OBJECTIVES: The objectives of this study were to assess the ability of pediatric health care providers and social workers to recognize sentinel injuries in infants under 6 months of age and to determine what factors influence their decision to evaluate for physical abuse. METHODS: A statewide collaborative focused on sentinel injuries administered a survey to pediatric health care providers and social workers in the emergency department, urgent care, and primary care. The survey contained 8 case scenarios of infants under 6 months of age with an injury, and respondents were asked if they would consider the injury to be a sentinel injury requiring a physical abuse evaluation. Respondents were then presented with several factors and asked how much each influences the decision to perform a physical abuse evaluation. RESULTS: A total of 565 providers completed the survey. Providers had moderate interrater reliability on their classification of the cases as sentinel injuries or not (κ = 0.57). Nearly all respondents (97%) recognized genital bruising as a sentinel injury, whereas 77% of respondents recognized intraoral injuries. Agreement was highest among social workers (κ = 0.76) and physicians with categorical pediatrics training and pediatric emergency medicine fellowship (κ = 0.63) and lowest among nurse practitioners (κ = 0.48) and residents (κ = 0.51). Concern over missing the diagnosis of abuse had the greatest influence on the decision to perform a physical abuse evaluation. CONCLUSIONS: Sentinel injuries are not uniformly recognized as potential signs of child abuse requiring further evaluation by pediatric health care providers. Additional evidence and education are needed regarding sentinel injuries.

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

OBJECTIVES: Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age. METHODS: A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis. RESULTS: Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively. CONCLUSION: Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).

Characteristics of Neighborhoods Where Emergency Medical Services Encounter Children at Risk for Maltreatment.

Objective: The objective of this study was to determine if neighborhood rates of pediatric Emergency Medical Services (EMS) encounters correlate with rates of child maltreatment reporting and if there are neighborhood-level risk factors for EMS encountering children with maltreatment reports. Methods: We conducted a retrospective cohort study using the electronic medical records of children ages <18 years who had Columbus Division of Fire EMS encounters between 2011 and 2015. We used Nationwide Children's Hospital electronic medical records to identify child maltreatment reports. The EMS scene addresses and home addresses associated with maltreatment reports were geocoded independently and rates for each Census tract were calculated. The maltreatment reports were matched to the EMS encounters using name, gender, and date of birth. Rates of EMS encounters with children that had a maltreatment report were calculated for each Census tract. Census tract demographic information was obtained from the American Community Survey. Bayesian conditional autoregressive Poisson models were used to calculate rate ratios for census tract variables to determine their relationship to EMS encountering children with maltreatment reports. Results: A total of 44,002 EMS encounters and 4,298 maltreatment reports were included in the study. The Spearman correlation coefficient relating rates of EMS encounters to rates of maltreatment reports within census tracts was 0.72 (95% confidence interval, 0.65-0.77). Within the study period, a total of 1,134 EMS encounters were linked to 578 children with maltreatment reports. Poverty was the only independent risk factor for EMS encountering children with maltreatment reports. The multivariate analysis also identified protective factors, which included neighborhoods with higher proportions of residents who had bachelor's degrees, spoke a language other than English, and had the same residence the previous year. Conclusion: This study showed that in Franklin County, Ohio, neighborhoods with high EMS utilization had a strong positive correlation with areas that had high rates of child maltreatment reports. We also identified four neighborhood characteristics that were independently associated with EMS encountering children at risk for maltreatment (risk factor: poverty; protective factors: residents with college educations, non-English speaking households, and residents maintaining the same residence as the previous year).

Prevalence of baby bottle versus breastfeeding graphics on products in national chain stores.

OBJECTIVE: This study surveyed the prevalence of bottle versus breastfeeding graphic images on products marketed for pregnant mothers and young children available for purchase in national chain stores. STUDY DESIGN AND METHODS: This was a product survey/content analysis. Eighteen national chain stores located in a 10-mile radius of Charlottesville, VA were visited. In total, 2,670 individual items in 11 categories of baby shower and baby gift merchandise (shower invitations, greeting cards, gift wrap, shower decorations, baby dolls, baby books, infant clothing, bibs, nursery decorations, baby blankets, and disposable diapers) were assessed. The main outcome measures were prevalences of baby bottle and breastfeeding graphic images. RESULTS: Baby bottle images were found on products in eight of the 11 categories of items surveyed. Thirty-five percent of baby dolls were marketed with a baby bottle. The prevalence of bottle images on items in all other categories, however, was low. Of the 2,670 items surveyed, none contained a breastfeeding image. CONCLUSIONS: The low prevalence of baby bottle images on commonly purchased baby gift and baby shower items is encouraging. However, the absence of breastfeeding images and the relatively high prevalence of baby dolls marketed with a baby bottle demonstrate that breastfeeding is not portrayed as the physiologic norm on these products. Product designers should explore ways to promote breastfeeding, consumers should make informed choices in product selection, and advocacy groups should promote guidelines for these products.