Case of Accidental Trauma Resulting in Condylar Fractures in 3-Month-Old.

While mandibular fractures represent the most common craniofacial injury in the pediatric population, craniofacial fractures in infants are rare. Diagnosis is challenging with nonspecific presenting symptoms and often limited radiographic imaging. We report a case of nondisplaced mandibular condylar head fractures in a 3-month-old patient as a result of a fall with impact onto the chin, with associated sublingual hematoma (Coleman's sign). Although the initially observed sole finding of sublingual hematoma raised concern for child physical abuse, detailed history, oral exam, and multidisciplinary review of radiologic records by pediatrics, otolaryngology, and child protection teams established the accidental trauma diagnosis. The patient was managed conservatively with normal resumption of feeding. Detailed history and multidisciplinary approach to the management of pediatric facial trauma are important in establishing diagnoses and management.

Understanding Bilateral Skull Fractures in Infancy: A Retrospective Multicenter Case Review.

BACKGROUND: Bilateral skull fractures in infancy often raise suspicion for abuse. Nevertheless, literature suggests that they may occur accidentally. However, empiric data are lacking. OBJECTIVE: This multicenter retrospective review aimed to characterize bilateral skull fractures in a large sample. PARTICIPANTS AND SETTING: Medical records for infants younger than 24 months with bilateral skull fractures involving hospital consultation with a child abuse pediatrician (CAP) were reviewed from 2005 to 2020 at 13 nationally represented institutions. METHODS: Standardized data collection across institutions included historical features, fracture characteristics, and additional injuries, as well as the CAP's determination of accident versus abuse. Pooled data were analyzed for descriptive and bivariate analyses. RESULTS: For 235 cases, 141 were accidental, and 94 abuse. The majority occurred in young infants, and a history of a fall was common in 70% of cases. More than 80% involved both parietal bones. Bilateral simple linear fractures were more common in accidental cases, 79% versus 35%, whereas a complex fracture was more frequent in abuse cases, 55% versus 21% ( P < 0.001). Almost two thirds of accidental cases showed approximation of the fractures at the sagittal suture, compared with one third of abuse cases ( P < 0.001). Whereas focal intracranial hemorrhage was seen in 43% of all cases, diffuse intracranial hemorrhage was seen more in abuse cases (45%) than accidents (11%). Skin trauma was more common in abusive than accidental injury (67% vs 17%, P < 0.001), as were additional fractures on skeletal survey (49% vs 3%, P < 0.001). CONCLUSIONS: A fall history was common in bilateral skull fractures deemed accidental by a CAP. Most accidental cases involved young infants with biparietal simple linear fractures, without skin trauma or additional fractures. A skeletal survey may aid in the determination of accidental or abusive injury for unwitnessed events resulting in bilateral skull fractures in infants.

Trends, Diagnoses, and Hospitalization Costs of Child Abuse and Neglect in the United States of America.

We conducted a secondary analysis of the National Inpatient Sample (NIS) to examine child abuse and neglect hospitalization from 1998-2016. The NIS is the largest all-payer, inpatient care database in the United States and is maintained by the Health Care Utilization Project. Participants were youth 18 years and younger with discharged diagnoses of child abuse and neglect from hospitals. The rate of child abuse or neglect hospitalizations did not vary significantly over the study period (1998-2016), which on average was 6.9 per 100,000 children annually. Males (53.0%), infants (age < 1; 47.3%), and young children (age 1-3; 24.2%) comprised most of the child maltreatment cases. Physical abuse was the most frequent type of maltreatment leading to hospitalization. Government insurance was the most common payer source, accounting for 77.3% of all child maltreatment hospitalizations and costing 1.4 billion dollars from 2001-2016. Hospitalizations due to child abuse and neglect remain steady and are costly, averaging over $116 million per year. The burden on government sources suggests a high potential for return on investment in effective child abuse prevention strategies.

Trends in shaken baby syndrome diagnosis codes among young children hospitalized for abuse.

OBJECTIVE: To investigate national trends of SBS diagnosis codes and how trends varied among patient and hospital characteristics. METHODS: We examined possible SBS, confirmed SBS, and non-SBS abuse diagnosis codes among children age three and younger who were hospitalized for abuse between 1998 and 2014 using a secondary analysis of the National Inpatient Sample, the largest US all-payer inpatient care database (N = 66,854). A baseline category logit model was used based on a quasi-likelihood approach (QIC) with an independent working correlation structure. RESULTS: The rate (per 100,000 census population of children age 3 and younger) of confirmed and possible SBS diagnosis codes was 5.4 (± 0.3) between 1998 and 2014, whereas the rate of non-SBS abuse was 19.6 (± 1.0). The rate of confirmed SBS diagnosis codes increased from 3.8 (± 0.3) in 1998 to 5.1 (± 0.9) in 2005, and decreased to 1.3 (± 0.2) in 2014. Possible SBS diagnosis codes were 0.6 (± 0.2) in 1998, increasing to 2.4 (± 0.4) in 2014. Confirmed SBS diagnosis codes have declined since 2002, while possible SBS diagnosis codes have increased. All abuse types were more frequent among infants, males, children from low-income homes, and urban teaching hospitals. CONCLUSIONS: We investigated seventeen-year trends of SBS diagnosis codes among young children hospitalized for abuse. The discrepancy between trends in possible and confirmed SBS diagnosis codes suggests differences in norms for utilizing SBS diagnosis codes, which has implications for which hospital admissions are coded as AHT. Future research should investigate processes for using SBS diagnosis codes and whether all codes associated with abusive head injuries in young children are classified as AHT. Our findings also highlight the relativity defining and applying SBS diagnosis codes to children admitted to the hospital for shaking injuries. Medical professionals find utility in using SBS diagnosis codes, though may be more apt to apply codes related to possible SBS diagnosis codes in children presenting with abusive head injuries. Clarifying norms for SBS diagnosis codes and refining definitions for AHT diagnosis will ensure that young children presenting with, and coded for, abusive head injuries are included in overall counts of AHT based on secondary data of diagnosis codes. This baseline data, an essential component of child abuse surveillance, will enable ongoing efforts to track, prevent, and reduce child abuse.

The Burden of Adverse Childhood Experiences in Children and Those of Their Parents in a Burn Population.

The aim of this study was to determine the prevalence, type, and associations of parental and child adverse childhood experiences (ACEs) in children presenting with burn injuries. Parents of burned children completed an ACE-18 survey, including questions on parent and child ACEs, needs, and resiliency. Demographics, burn injury, hospital course, and follow-up data were collected. Family needs and burn outcomes of children with and without ACEs' exposure (no ACE vs one to two ACEs vs three or more ACEs) were analyzed. P <.05 was considered significant. Seventy-five children were enrolled-58.7% were male, 69.3% white. The average age was 6.0 ± 5.2 years. The average total burn surface area was 4.4 ± 5.7% (0.1-27%). Parent ACE exposure correlated with child ACE exposure (r = .57; P = .001) and this intensified by increasing child age (P = .004). Child ACE exposure showed a graded response to family needs, including food and housing insecurity and childcare needs. Stress and psychosocial distress of the parents was significantly associated with their children's ACE burden. The ACE burden of parents of burned children can affect the ACE load of their children. Burned children with more ACEs tend to have significantly more needs and more family distress. Awareness of past trauma can help identify a vulnerable population to ensure successful burn recovery.

Nationwide efforts for trauma-informed care implementation and workforce development in healthcare and related fields: a systematic review.

There is building evidence that Adverse Childhood Experiences without early and proper intervention leads to subsequent short- and long-term behavioral, social, physical and mental health problems. Practitioners, researchers, and healthcare systems have been implementing trauma-informed care (TIC) in a variety of health and human services settings, resulting in improvements in clinical care and prevention of illness by identifying high risk populations. This has led to positive health outcomes including improved compliance, better access to mental health services and reduced health care costs. A systematic review was conducted of studies that focused on TIC implementation in healthcare settings, statewide TIC implementation, impact of adverse childhood experiences on health outcomes, impact of TIC on health outcomes, and evaluation of TIC implementation. A search was conducted in March 2019 to identify studies in PubMed, Medline, and other online literature. We limited our search to articles published in English after 2000. This article aims to review the components of TIC phases of implementation in healthcare settings, success stories across the nation to help the readers understand the importance of a paradigm shift to improve healthcare delivery and health outcomes and to prevent illness starting from childhood with a family centered care perspective.

Statement of the Independent Forensic Expert Group on Conversion Therapy.

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

A national educational campaign to raise awareness of child physical abuse among health care professionals.

Education is necessary to improve child physical abuse detection and management. A few studies have described national child abuse training programs, but none has measured changes in knowledge among participants. A collaboration of child abuse experts from the USA, an academic pediatric department, and a non-governmental organization in child protection aimed at (a) training hospital physicians in a train-the-trainer course for the detection and management of child physical abuse and (b) conducting workshops and measuring attendance and gain of knowledge of participants. A train-the-trainer and a national curriculum were created. A 78-item and a 20-item knowledge questionnaire were used pre and post the train-the-trainer course and all workshops, respectively. Nineteen physicians from all pediatric departments of the seven medical schools in Greece attended the course. Eight workshops in seven cities took place with a total attendance of 1220 health care professionals. Gain of knowledge was demonstrated for participants in the train-the-trainer course (p = 0.0015) and local workshops (p < 0.001).Conclusion: We successfully engaged physicians from all medical schools in Greece and conducted a train-the-trainer module and eight workshops in major cities that improved the participants' knowledge in child physical abuse. This approach may help address physician deficiencies in emerging areas of child abuse clinical practice. What is Known: • Education is necessary to improve child physical abuse detection and management. • Although national training programs have been described, none has measured participants' changes in knowledge. What is New: • A collaboration of child abuse experts, all medical schools in Greece, and a non-governmental organization resulted in a national educational campaign in child physical abuse and gains in knowledge for participants. • This approach may help address deficiencies in emerging areas of clinical practice.

Two-generational trauma-informed assessment improves documentation and service referral frequency in a child protection program.

BACKGROUND: Two-generational trauma-informed assessment (TIA) helps providers conduct holistic family well-being assessment (FWbA). This tool makes it possible to use families' trauma history in the case-finding process. OBJECTIVE: This study compares the documentation and frequency of adverse childhood experiences (ACEs) and service referral rates for index children and their caretakers in two groups of families evaluated in a child abuse clinic (CAC). PARTICIPANTS AND SETTING: The sample consisted of 364 children stratified into two groups: Group 1 - children seen in the CAC after implementation of FWbA in years 2014, 2015, 2016 and Group 2 - children seen in the CAC prior to implementation of FWbA in years 2011, 2012, 2013. METHODS: Researchers utilized retrospective chart review method and analyzed data regarding ACEs and service referrals for patients and their caregivers. RESULTS: Documentation of ACEs was higher in Group 1 for children (77.7 % vs 26.6 %,p <  0.0001) and caretakers (60.7 % vs 7.3 % p <  0.0001). Caretakers in Group 1 had a higher rate of four or more ACEs (47.0 % vs 5.1 % p <  0.001) while the increase for children was not statistically significant (61.4 % vs 51.1 %, p =  0.110). Both children and caretakers were referred to more services in Group 1 (2.7 + 1.5 vs 1.5 + 1.3, and 3.0 + 1.9 vs 1.2 + 1.2, respectively, p <  0.0001). CONCLUSIONS: In families evaluated for child abuse and neglect, conducting TIA in addition to conventional psychosocial evaluation increased documentation regarding trauma history, which led to increased referral rates.

The Impact of Adverse Childhood Experiences on Burn Outcomes in Adult Burn Patients.

Adverse childhood experiences (ACEs), including child maltreatment and household dysfunction, define adverse events that occur before 18 years of age. National and state data show that between 12.5 and 14.5% of the adult population report ≥4 ACEs (HIGH-ACE), respectively. HIGH-ACEs are associated with more chronic health problems. To date, the interaction between ACEs and burn injuries has not been studied. Herein, we sought to define the ACE exposure in our burn patients and its impact on early outcomes. Inpatient and outpatient adult burn survivors (≥18 years of age) were enrolled. Subjects completed surveys assessing adverse experiences (ACEs-18), needs, strengths, and resiliency at consent, and pain, depression, post-traumatic stress disorder (PTSD), and social participation surveys at 2 weeks to 3 months postinjury. Demographics, burn, and hospital course data were also collected. Chi-square and student's t-tests were used for descriptive analysis and to compare the groups (HIGH-ACE vs LOW-ACE). The HIGH-ACE group (n = 24; 45.3%) reported more depressive symptoms (P < .04) than the LOW-ACE group (n = 29, 54.7%). HIGH-ACE patients were less resilient when facing stressful events (P ≤ .02) and more likely to screen positive for probable PTSD (P = .01) and to score lower on the Life Impact Burn Recovery Evaluation Profile (LIBRE Profile), which assesses for social participation, in the domain of Family and Friends (P = .015). Our exploratory study suggests that ACE screening may help detect burn patients at risk for a more complicated recovery, thereby promoting personalized assistance in recovery.

Child abuse and neglect experts' determination of when a child being left home alone constitutes child neglect.

BACKGROUND: Only 14 states have laws or guidelines regarding the minimum age a child may be left home alone. These ages range from 6 to 14 years. Our objective was to identify factors that influence child neglect determination by experts with regards to parents leaving children home alone. METHODS: American Academy of Pediatrics Section on Child Abuse and Neglect members (N = 523) were surveyed from July-August, 2015. Respondents were asked whether scenarios involving a child of varying age knowingly left home alone for 4 h were neglect in the presence or absence of injury to the child and the legality of the situation. Comparisons were performed using the chi-square test. RESULTS: One hundred ninety-three members responded (36.9%). In the scenario where there were no relevant laws and the child was uninjured, nearly 100% of the child experts determined this as being child neglect when the child was 6 years old. For 8, 10, 12, and 14 year olds, this was 88, 48, 4, and 1%, respectively. However, a significantly higher percentage of experts considered it child neglect for most ages when there was a law making the scenario illegal as compared when there was no law, and when the child was injured versus when they were not. The only demographic variable that showed a difference in child neglect determination was that females were more likely to consider higher aged children as having been neglected when there were no laws but the child was injured. The vast majority of experts (85%) stated that leaving a child home alone for 4 h should be illegal if the child is < 9 years old, and nearly one-half (44%) said it should be illegal for children < 11 years old. CONCLUSIONS: A number of factors affect how experts view children being left home alone as potential child neglect. Our data suggests that such cases may be evaluated differently due to variations in state laws, even though the risk to the child is the same. These results call for child safety law reform to provide greater uniformity in the evaluation of potential child neglect cases and better protect the safety of children.

Measuring awareness about child abuse and neglect: Validity and reliability of a newly developed tool-child abuse and neglect awareness scale.

Altan H, Budakoglu II, Sahin-Dagli F, Oral R. Measuring awareness about child abuse and neglect: Validity and reliability of a newly developed tool-child abuse and neglect awareness scale. Turk J Pediatr 2018; 60: 392-399. In this study, we aimed at determining child abuse and neglect awareness of medical students attending one of the top medical schools in Turkey. The study group comprised 350 third-year medical students at Gazi University, School of Medicine, Ankara. The items in the scale were prepared by two experienced pediatricians and revised according to feedback received from two pilot studies and experts in this field of study. A 20-item `Child Abuse and Neglect Awareness` scale (CANA-S) was developed by an expert panel. Exploratory and confirmatory factor analyses were performed. We also measured test-retest reliability and internal consistency. Conformity for factor analysis of the scale`s construct validity revealed a Kaiser-Meyer-Olkin sample concordance coefficient of 0.799. For the Bartlett Sphericity test, χ2 value was 1157.750 (p < 0.01). Based on these analyses, the scale explains 44.9% of the total variance and consists of 20 items and 4 subscales. Cronbach`s alpha value and correlation coefficient were 0.768 and r=0.204 (p=0.045), respectively. This scale is a valid and reliable measurement tool for evaluating awareness about child abuse and neglect among the medical students.

Child welfare professionals' determination of when children's access or potential access to loaded firearms constitutes child neglect.

BACKGROUND: Pediatric deaths and injuries from access to firearms are a significant public health problem. No studies have examined how experts determine child neglect regarding firearm access in the home. Our study objectives were to identify factors that influenced pediatric experts' finding of firearm-related child neglect and to assess their attitudes toward child access prevention (CAP) laws. METHODS: A survey was distributed to the American Academy of Pediatrics Section on Child Abuse and Neglect members. Demographics, attitudes regarding CAP laws, and ages (up to 14 years old) at which experts deemed several scenarios as child neglect were determined. Scenarios tested potential versus actual loaded firearm access, presence or absence of a CAP law, and injury versus no injury when the firearm was accessed. RESULTS: One hundred ninety-three surveys were completed. Experts agreed (>95%) that CAP laws were important, even for children up to age 15 years. Although a high percentage considered potential access to a loaded firearm as child neglect, a CAP law significantly increased the percentage for each age. In addition, higher percentages of respondents from states with CAP laws than those without deemed potential access as child neglect for 12- and 14-year-olds. In contrast, if the child had accessed a loaded firearm, there were no significant differences in the high percentages that deemed the scenario as child neglect under any conditions, including with and without a CAP law. CONCLUSIONS: Although almost all child neglect experts considered potential and actual access to loaded firearms as child neglect, CAP laws increased the percentage for cases of potential access. Universal CAP laws may help ensure that determinations of child neglect are more consistent across states. The deterrent effect of potential child neglect findings may increase the number of parents securing firearms in ways that prevent child access and reduce firearm-related deaths and injuries. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Adverse childhood experiences and trauma informed care: the future of health care.

Adverse childhood experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care (TIC) in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity, and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.

Quantitative measurement of retinal hemorrhages in suspected victims of child abuse.

PURPOSE: Child abuse is one of the leading causes of death in early childhood. The presence of retinal hemorrhages often supports the diagnosis. The purpose of this study was to determine whether the specific measurement of retinal hemorrhages when present on fundus photography correlates with other clinical findings typically seen in children suspected of having been abused. METHODS: The medical records of children with retinal hemorrhages who were suspected of being victims of abusive head trauma from June 2003 to June 2013 and who had widefield retinal photography performed were retrospectively reviewed. Data collected included hemorrhage-covered percentage (HCP) of the central retina (posterior pole or 40° circle centered on fovea) measured by ImageJ in relation to death, length of hospital stay, presence of abnormal findings on neuroimaging or skeletal survey, and definite versus possible abuse. RESULTS: Significant difference in retinal hemorrhage measured on fundus photography was found in patients with axial skeletal fracture (P = 0.016), signs of severe brain trauma on neuroimaging (P = 0.014) and definite versus possible abuse (P = 0.023). No correlation of quantitative measurement of the retinal hemorrhage to length of hospital stay, death, or the presence of skull fracture was found in this cohort. CONCLUSIONS: The quantitative measurement of total retinal hemorrhage when present on fundus photography centered on posterior pole in children suspected of having been abused correlated with some but not all findings typically seen in abused children.

Missed cases of multiple forms of child abuse and neglect.

Child abuse and neglect is a public health problem and usually associated with family dysfunction due to multiple psychosocial, individual, and environmental factors. The diagnosis of child abuse may be difficult and require a high index of suspicion on the part of the practitioners encountering the child and the family. System-related factors may also enable abuse or prevent the early recognition of abuse. Child abuse and neglect that goes undiagnosed may give rise to chronic abuse and increased morbidity-mortality. In this report, we present two siblings who missed early diagnosis and we emphasize the importance of systems issues to allow early recognition of child abuse and neglect.

Factors related to child maltreatment in children presenting with burn injuries.

The underpinnings of maltreatment in children presenting with burn injuries are necessary to discern as detection and prevention rest on a clear delineation of factors associated with maltreatment. Inaccurate identification of child victims can result in perpetuation of the maltreatment and its attendant neuropsychological sequela. The authors sought to determine factors associated with maltreatment in children presenting with burn injuries, which would guide the burn team in assessing the likelihood of maltreatment. All consenting children admitted with burn injuries were surveyed regarding their injury mechanism and current sociodemographic status. Suspicious injuries were referred by the burn team to the multidisciplinary review team (MRT). The MRT reported injuries with signs of physical abuse, supervision neglect, neglect of other basic needs, or sexual abuse. These children constituted the cases in our study. Variables related to maltreatment were entered into stepwise logistic regression to identify independent predicting variables. P< .05 was considered significant. MRT identified 16 children (24%) admitted with burn injuries with suspicions of maltreatment. Risk factors related to suspicions of maltreatment included: young age, large burns, tap water injury, immersion lines, delay in care, absence of a two-parent family (unconventional family structure), young parents, inconsistent history, and injury pattern. In this single-center prospective study, the authors identified several factors that, when present in injuries with initial suspicion of maltreatment, should trigger a child maltreatment workup. Burn clinicians have an important role as advocates for children and their families. It is important to continue to further the knowledge of maltreatment detection and prevention among children presenting with burn injuries.

Retinal hemorrhages in intubated pediatric intensive care patients.

PURPOSE: To define the diagnoses associated with the presence of retinal hemorrhages, to clarify the association between retinal hemorrhages, cardiopulmonary resuscitation (CPR), and coagulopathy, and to describe the type of retinal hemorrhages found in intubated critically ill patients <4 years of age. METHODS: This was a prospective observational study of intubated patients <4 years of age admitted to the pediatric intensive care unit of a tertiary care center from March 2010 to May 2012. The presence and description of retinal hemorrhages was recorded along with diagnoses, international normalized ratio (INR), CPR (in minutes), and mortality. RESULTS: A total of 85 intubated, critically ill patients (37 females) were included; average patient age was 8.2 months (range, 0.1-46.8 months). Of the 85 patients, 6 (7%) had retinal hemorrhages (95% CI, 0.029-0.153). Of the 6 patients with RH, abusive head trauma (AHT) was diagnosed in 4 patients, 1 patient had direct head trauma, and 1 had CPR. There were 8 patients with CPR out of the 85. AHT was highly associated with severe multilayered retinal hemorrhages (P = 0.0001) but coagulopathy (P = 0.2671) and CPR (P = 0.5342) were not. CONCLUSIONS: Severe multilayered retinal hemorrhages were associated with AHT in this cohort of patients. Without a history of trauma, retinal hemorrhages occurred in only 1 of 85 patients; in this case the hemorrhages were mild, confined to the posterior pole, and found only in the retinal layer.

Staff training makes a difference: improvements in neonatal illicit drug testing and intervention at a tertiary hospital.

OBJECTIVE: This project explored the impact of staff training on the rates of perinatal maternal and neonatal illicit drug testing. METHODS: Controlled, retrospective chart review on 1186 newborn and mother dyads from 2006 (pre-training control group) and on 1861 dyads from 2009 (post-training study group) was completed. Differences between rates of infant and mother drug testing were compared. RESULTS: Increased drug testing rates for the mothers and infants led to increased case finding that tripled both for the mothers (13-3.7%, p < 0.001) and for the infants (0.9-2.9%, p < 0.001). Missed opportunities for newborn testing was reduced by 35 times (20.9-0.6%, p < 0.001). CONCLUSION: This retrospective study led to an increase in the number of documented drug-exposed newborns. This research emphasizes the importance of and encourages other hospitals to analyze the efficacy of their current protocol and staff training practices in place to ensure the best child protection services.

Epidemiological study of negative childhood experiences in three provinces of Turkey.

AIM: This study aimed to determine the frequencies of negative childhood experiences in the past years and negative childhood experiences throughout life in 11, 13 and 16 year-age group children who attended school in three separate provinces. MATERIAL AND METHODS: Approval was obtained from the provincial National Education Directorates and educated investigators applied the ISPCAN child abuse screening tool questionnaire form which measures negative childhood events experienced at home in children. Statistical analysis was performed with chi-square test using SPSS 16.0 program. Approval from the ethics committee was obtained from Izmir Tepecik Education and Research Hospital Chief Physician Office Local Ethics Committee (29/11/2011-29). RESULTS: The study was conducted with 7 540 children in Izmir, Denizli and Zonguldak. The frequency of psychological and physical negative childhood experiences and neglect throughout life was found to be 70.5%, 58.3% and 42.6% in the 11, 13 and 16-year age groups, respectively; the frequencies in the last one year was found to be 62.7%, 46.0% and 37.5%, respectively. Psychological negative childhood experiences were found with a higher rate in children who lived in urban areas compared to children who lived in rural areas. Neglect was found with a higher rate in girls and physical negative childhood experiences were found with a higher rate in boys. The frequency of negative childhood experiences increased proportionally with the age of the child independent of the type of experience. CONCLUSION: The frequencies of negative childhood experiences for the last one year and for the life-long period were determined using ISPCAN child abuse screening tool in Turkey for the first time in three provinces and in such a large population. The frequency of negative childhood experiences related with child abuse and neglect screened were found to be 42%-70% and it was elucidated that we are confronted with a very significant public health problem and adult health risk in these regions of Turkey.