Care coordination for children with a disability or developmental difficulty: Empowers families and reduces the burden on staff supporting them.

BACKGROUND: Almost half of all children and young people with a disability or developmental difficulty (DDD) have complex disability and are likely to require multidisciplinary care. Care coordination (CC) aims to provide a single point of contact and a coordinated service, thereby improving care experiences, meeting unmet needs and empowering families. The impact of CC for children with DDD was evaluated. METHOD: Between May and August 2020, an in-depth evaluation of CC in Gwent, South Wales was conducted. Of 284 families who accessed CC, 38 were approached, as well as 177 health and social care professionals based at Serennu, Nevill Hall and Caerphilly Children's Centres. Nine families and 14 professionals completed semi-structured interviews. Interview transcripts were analysed using thematic analysis. RESULTS: This evaluation found perceived improvements in families' abilities to navigate, organize and understand care and increased parental engagement. Professionals observed fewer missed appointments, and both professionals and families described CC as a source of holistic support, including practical advice regarding housing, finances and emotional support. Professionals commented on CC easing pressure on their service. Potential limitations included restricted staff capacity and the role not being defined clearly for families and professionals. CONCLUSIONS: At a time of increased stress for families of children with DDD, and scarce resources to support them, care coordinators play a vital role in assisting families to engage with health services, while feeling supported and empowered. CC reduces the burden on professionals, while enhancing relationships with families.

Lazarus Syndrome - Challenges Created by Pediatric Autoresuscitation.

ABSTRACT: Pediatric autoresuscitation is extremely rare, with only 4 documented cases in the literature. The longest recorded time between stopping cardio pulmonary resuscitation (CPR) and return of spontaneous circulation is 2 minutes. We report a previously well 18-month-old who attended the emergency department after an unexplained cardiac arrest. After 10 cycles of CPR, resuscitation was stopped; 6 minutes later, the patient had a return of spontaneous circulation and was transferred to the pediatric intensive care unit. The patient remains alive but with significant neurological impairment. There are a variety of theories regarding the pathology of pediatric autoresuscitation. The most commonly accepted model is that there is a degree of autopositive end-expiratory pressure impending venous return as a consequence of vigorous ventilation during CPR. This case challenges clinicians to reassess our current definition of death and reaffirms the need for clearer guidelines surrounding the certification of death.

"They just get it" an exploration of father's experiences and perceptions of a support group for men caring for children with disabilities and/or developmental delay.

BACKGROUND: Support groups available to parents/carers of children with a disability or developmental delay (DDD) are predominately attended by women. Limited data exists reporting experiences of the few male-only support groups. This paper examines experiences of fathers of children with DDD attending a male-only support group from South Wales. METHOD: All fifteen members from a support group for fathers/male carers of children with DDD were invited to take part in qualitative interviews and seven participated. The data were analysed following Braun and Clarke's (Qualitative research in psychology, 2006, 3:77) thematic framework. RESULTS: Within the group, fathers felt understood by similarly situated men, and a sense of connectivity and belonging. Fathers perceived exclusion elsewhere, including mixed-gender groups. Fathers felt permission to talk in a way consistent with their male identities, and valued receiving, and giving, support. CONCLUSIONS: Mixed-gender support groups may not meet the needs of fathers, and there are potential benefits in providing male-only groups.

Incidence of medically attended paediatric burns across the UK.

OBJECTIVE: Childhood burns represent a burden on health services, yet the full extent of the problem is difficult to quantify. We estimated the annual UK incidence from primary care (PC), emergency attendances (EA), hospital admissions (HA) and deaths. METHODS: The population was children (0-15 years), across England, Wales, Scotland and Northern Ireland (NI), with medically attended burns 2013-2015. Routinely collected data sources included PC attendances from Clinical Practice Research Datalink 2013-2015), EAs from Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI, 2014) and National Health Services Wales Informatics Services, HAs from Hospital Episode Statistics, National Services Scotland and Social Services and Public Safety (2014), and mortality from the Office for National Statistics, National Records of Scotland and NI Statistics and Research Agency 2013-2015. The population denominators were based on Office for National Statistics mid-year population estimates. RESULTS: The annual PC burns attendance was 16.1/10 000 persons at risk (95% CI 15.6 to 16.6); EAs were 35.1/10 000 persons at risk (95% CI 34.7 to 35.5) in England and 28.9 (95% CI 27.5 to 30.3) in Wales. HAs ranged from 6.0/10 000 person at risk (95% CI 5.9 to 6.2) in England to 3.1 in Wales and Scotland (95% CI 2.7 to 3.8 and 2.7 to 3.5, respectively) and 2.8 (95% CI 2.4 to 3.4) in NI. In England, Wales and Scotland, 75% of HAs were aged <5 years. Mortality was low with 0.1/1 000 000 persons at risk (95% CI 0.06 to 0.2). CONCLUSIONS: With an estimated 19 574 PC attendances, 37 703 EAs (England and Wales only), 6639 HAs and 1-6 childhood deaths annually, there is an urgent need to improve UK childhood burns prevention.

Radiological features of healing in newborn clavicular fractures.

OBJECTIVES: Given the frequency of abusive fractures among infants, and the lack of research and or evidence for the phases of fracture healing seen in this age group, this study aims to describe a timetable of radiological features of fracture healing among infants in the first months of life. METHODS: We completed a retrospective cross-sectional time-series study of birth-related clavicle fractures from 2006-2013. A total of 108 digital images were available for review from 61 infants. The presence or absence of four features of healing including periosteal reaction, callus formation, bridging callus and remodelling were scored by three radiologists. RESULTS: The level of agreement between the radiologists was good to high (0.60-0.90). Features of healing were first seen at 7 days (periosteal reaction), 11 days (callus), 20 days (bridging) and 35 days (remodelling), respectively. The peak periods that each feature was present are as follows: periosteal reaction 11-42 days, callus 12-61 days, bridging 22-63 days and remodelling 49-59 days. CONCLUSIONS: Birth-associated clavicle fractures in infants follow a logical progression of healing changes. Understanding the expected progression and timing of fracture healing may be helpful as it pertains to the timing of injury in cases of abuse in infants. KEY POINTS: • Large study describing the time frames of fracture healing in young infants. • Features of fracture healing develop in a logical progression. • Evidence provided for determining fractures are consistent with a proposed time frame. • It is of critical importance to have sound evidence for the dating of fractures.

Paediatric approaches to child maltreatment are subject to wide organisational variations across Europe.

AIM: Little is known about the organisation of child maltreatment practice in Europe. We therefore explored medical child protection systems and training across Europe. METHODS: An online survey was completed by physicians working in child maltreatment, identified through professional organisations in 28 member countries of the European Union, Iceland, Norway and Switzerland in 2012-2013. Respondents were questioned regarding management of suspected child maltreatment, mandatory reporting, professional training, patient referral and physician roles in multidisciplinary investigations. Responses underwent a narrative synthesis and descriptive enumerations. RESULTS: The survey was completed by 88 individuals, unevenly distributed in 22 of 31 countries. Physicians were mandated to report child maltreatment in 16 of 22 countries. All of 88 responding physicians described multidisciplinary involvement in the clinical and forensic management of suspected child maltreatment. Practitioners involved in physical examinations included general physicians, paediatricians, forensic medical examiners, gynaecologists and paediatric surgeons. Paediatricians were required to undergo child protection training according to 30 of 86 respondents in 14 of 22 countries. CONCLUSION: This survey demonstrates that there were wide variations in the organisation of child maltreatment paediatrics in Europe. The differing legislative frameworks and models of care are pertinent to consider when comparing epidemiology of maltreatment reported from across European countries.

A study of radiological features of healing in long bone fractures among infants less than a year.

PURPOSE: To create a timetable for dating long bone fractures in infants aged less than 1 year using previously defined radiographic signs of fracture healing. MATERIALS AND METHODS: A retrospective cross-sectional time series of long bone fractures in infants aged less than 1 year was conducted from 2006 to 2013. After exclusion criteria were applied 59 digital image series were available for review from 40 infants. Utilizing published criteria for dating fractures, the presence or absence of four pre-defined features of healing was scored: periosteal reaction, callus, bridging, and remodeling. Three radiologists independently scored radiographs with a 3-point scale, marking each feature as present, absent, or equivocal. The times in days when features were first seen, peaked (feature agreed present in >40% of images), and last seen were noted. Statistical analysis using free marginal kappa was conducted. RESULTS: The level of agreement among the three radiologists was high (0.64-0.85). The sequence in which the features were seen was: periosteal reaction range 7-130 (present in the majority of cases between 9 and 49 days); callus range 9-130 (present in the majority of cases between days 9-26); bridging range 15-130 (seen in the majority of cases between 15 and 67 days); remodeling range 51-247 days. CONCLUSION: This study provides a timetable of radiological features of long bone healing among young infants for the first time. Dating of incomplete long bone fractures is challenging, beyond the presence of periosteal reaction, but a consistent sequence of changes is present in complete fractures.

A Systematic Review of the Probability of Asphyxia in Children Aged <2 Years with Unexplained Epistaxis.

OBJECTIVE: To determine the proportion of children aged <2 years who have been asphyxiated presenting with epistaxis in the absence of trauma or medical explanation and to identify the characteristics of the clinical presentation indicative of asphyxiation. STUDY DESIGN: An all-language systematic review was conducted by searching 10 databases from 1900 to 2015 and gray literature to identify high-quality studies that included children with epistaxis aged <2 years (alive or dead) with explicit confirmation of intentional or unintentional asphyxiation (upper airway obstruction). Studies of traumatic or pathological epistaxis were excluded. For each comparative study, the proportion of children presenting with epistaxis that were asphyxiated is reported with 95% CI. RESULTS: Of 2706 studies identified, 100 underwent full review, resulting in 6 included studies representing 30 children with asphyxiation-related epistaxis and 74 children with non-asphyxiation-related epistaxis. The proportion of children presenting with epistaxis that had been asphyxiated, reported by 3 studies, was between 7% and 24%. Features associated with asphyxiation in live children included malaise, altered skin color, respiratory difficulty, and chest radiograph abnormalities. There were no explicit associated features described among those children who were dead on arrival. CONCLUSION: There is an association between epistaxis and asphyxiation in young children; however, epistaxis does not constitute a diagnosis of asphyxia in itself. In any infant presenting with unexplained epistaxis, a thorough investigation of etiology is always warranted, which must include active exploration of asphyxia as a possible explanation.

Exploring the acceptability of a clinical decision rule to identify paediatric burns due to child abuse or neglect.

OBJECTIVE: An evidence based clinical decision rule (CDR) was developed from a systematic review and epidemiological study to identify burns due to child maltreatment (abuse or neglect). Prior to an implementation evaluation, we aim to explore clinicians' views of the CDR, the likelihood that it would influence their management and factors regarding its acceptability. METHODS: A semistructured questionnaire exploring demographics, views of the CDR and data collection pro forma, ability to recognise maltreatment and likelihood of following CDR recommended child protection (CP) action, was administered to 55 doctors and nurses in eight emergency departments and two burns units. Recognition of maltreatment was assessed via four fictitious case vignettes. ANALYSIS: Fisher's exact test and variability measured by coefficient of unalikeability. RESULTS: The majority of participants found the CDR and data collection pro forma useful (45/55, 81.8%). Only five clinicians said that they would not take the action recommended by the CDR (5/54, 9.3%). Lower grade doctors were more likely to follow the CDR recommendations (p=0.04) than any other grade, while senior doctors would consider it within their decision making. Factors influencing uptake include: brief training, background to CDR development and details of appropriate actions. CONCLUSIONS: It is apparent that clinicians are willing to use a CDR to assist in identifying burns due to child maltreatment. However, it is clear that an implementation evaluation must encompass the influential variables identified to maximise uptake.

Defining background DNA levels found on the skin of children aged 0-5 years.

There are currently no data available regarding the normal levels of DNA found on the skin of children engaging in routine day to day activities to assist with the forensic interpretation of DNA profiles generated from skin surface swabs. To address this deficit, skin surface swab samples were collected from 12 face/neck sites and 20 body sites on 50 children less than 5 years old. After exclusion of spoilt samples, 60 sets of swabs from 47 children (30 face/neck, 30 body) comprising of 944 individual samples were analysed. The number of alleles observed which could have originated from the child and the number which must have come from another source (non-child) were analysed. The following variables were evaluated: age, kissing, feeding and washing practices, number of contacts and application of cream. Overall, extremely small amounts of non-child DNA were retrieved from skin swabs. Child only (46.3%) or no DNA at all (18.6%) was observed for 64.9% of all swabbed samples. Low levels of non-child DNA (1-5 alleles) were observed on 31.6% of all swabs tested with only 3.4% of swabs showing six or more alleles. A great deal of variation between children and between sites in the levels of both child DNA and non-child DNA was observed. A multilevel model, taking account of clustering within children, showed that there was a strong direct association between the amounts of child and non-child DNA observed. There was no relationship between the amount of DNA recovered and the demographic and biographic variables analysed. These background data have the potential to assist the analysis of DNA from the skin of children during criminal investigation.

Spinal injuries in abusive head trauma: patterns and recommendations.

A growing body of scientific evidence suggests that there is an association between occult spinal injury and abusive head trauma (previously known as shaken baby syndrome). Consideration needs to be given to the nature of these injuries, the possible causal mechanisms and what investigations should be undertaken to delineate the full extent of spinal involvement in infants with suspected abusive head trauma. This association has the potential to influence our understanding of the biomechanics and subsequent neuropathology associated with abusive head trauma.

A timetable for the radiologic features of fracture healing in young children.

OBJECTIVE: Fracture dating significantly shapes decisions in child protection. With a dearth of primary evidence underpinning fracture dating in children, we examined the key radiologic features of fracture healing and their timelines. MATERIALS AND METHODS: Digital radiographs of children younger than 72 months old with accidental long bone fractures of known timing were reviewed independently by three pediatric radiologists blinded to the age of the fractures. Six radiologic features of fracture healing were evaluated: soft-tissue swelling, periosteal reaction, soft callus, hard callus, bridging, and remodeling. Interobserver agreement was assessed using kappa analysis. RESULTS: Two hundred twenty-eight films of 82 fractures in 63 children (mean age, 4.8 years) were assessed. Soft-tissue swelling was identified by two or more radiologists in 59% of the radiographs at days 1-2 after fractures, and prevalence sharply declined thereafter. Periosteal reaction was first seen at day 5 and was present in 62% of the films obtained between 15 and 35 days after the fracture. Soft callus was first seen at day 12 and was prevalent in 41% between 22 and 35 days. Hard callus and bridging began at day 19, increasing to 60% prevalence from 36 days onward. Remodeling was observed only in fractures 45 days old or more. Kappa scores were between 0.55 and 0.80 overall, with greater agreement when there was no plaster cast. CONCLUSION: The results of this study show that fractures in young children may be dated as acute (< 1 week), recent (8-35 days), or old (≥ 36 days) on the basis of the presence of six key radiologic features in combination. Furthermore, good interobserver agreement suggests these results are reproducible.

Which is the preferred image modality for paediatricians when assessing photographs of bruises in children?

Images of bruises serve as a clinical record and may facilitate forensic analysis in the assessment of suspected physical child abuse. Currently, only conventional imaging techniques are employed; however, alternative imaging modalities using visible and non-visible light may provide additional information. We sought to determine the image modality preferences of paediatricians and the between-observer agreement therein. Nine paediatricians who work in child protection independently compared five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared) of four bruises, with a compliance rate of 95%. All images were taken using a standardised set of protocols with Nikon D90 cameras and 105-mm macro-lenses. The paediatricians almost unanimously chose cross-Polarised as their preferred modality for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale imaging were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the least two favourable positions. Between-observer agreement on ranking order was high, with coefficients of concordance ranging from 0.76 to 0.96. Combinations of imaging modalities chosen to give the most complete picture of the bruise predominantly consisted of cross-Polarised and conventional (colour and grey-scale). This pilot study demonstrated that clinicians collectively favoured cross-Polarised in addition to conventional imaging. Further studies are required to determine the value of ultraviolet and infrared imaging in the assessment of childhood bruises.

Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE: Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)? DESIGN: Prospective comparative longitudinal study. SETTING: Community. PATIENTS: Children <6 years old. INTERVENTIONS: The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases. MAIN OUTCOME MEASURES: Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD. RESULTS: Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%. CONCLUSIONS: These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

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).

What Do Confessions Reveal About Abusive Head Trauma? A Systematic Review.

Although confessions related to abusive head trauma (AHT) are reported, no detailed analysis exists. Therefore, we systematically reviewed studies of AHT confessions and examined the details, including country of origin, mechanisms and perpetrators' characteristics [PUBLISHER - THE PRECEDING UNDERLINED TEXT IS FOR THE MARGIN]. Employing 36 search terms across three search engines, we searched Medline and CINAHL from 1963 to 2018. All relevant studies underwent two independent reviews and data extraction. Descriptive statistics were used to characterise the sample; chi square and Fisher's exact tests were used to assess differences in demographic and clinical characteristics. Of 6759 identified studies, 157 full texts were reviewed and 55 articles from 15 countries spanning four continents were included. Included articles contained 434 confessions. The mechanisms of abuse included shaking alone (64.1%), impact alone (17.1%), shaking plus impact (18.0%) and other (0.9%). There was no statistically significant difference in the percentage of confessions reporting shaking alone when comparing continents: North America (64.0%), Europe (64.2%) and Oceania (60.0%; P=.92), or when comparing circumstances in which the confession was obtained: medical evaluation (74.6%) vs police or judicial investigations (63.4%; P=.11). Of 119 cases with identified perpetrators, 67.2 per cent were cases with males alone. Confessions reveal striking similarities in the mechanism of AHT (predominantly shaking) and occur across the globe.

Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature.

Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.

Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings.

This project sought to assess the generalizability, barriers, and facilitators of implementing the Safe Environment for Every Kid (SEEK) model for addressing psychosocial risk factors for maltreatment across multiple primary care settings, including a pediatric practice, federally qualified health center, and family medicine practice. The SEEK model includes screening caregivers for psychosocial risk factors at well-child visits age 0 to 5 years, brief intervention incorporating principles of motivational interviewing to engage caregivers, and referral to treatment. All practices successfully implemented SEEK, with screening completion rates from 75% to 93% and brief intervention rates from 61% to 81%. Major parental stress (14%) and food insecurity (11%) were the most common risk factors. Providers found SEEK worthwhile for improving their knowledge, skills, and ability to address psychosocial concerns and provide whole person care. Barriers included limited time and resources, incomplete resource knowledge, and lack of follow-up. Facilitators included on-site support staff to assist with communication and referrals.