A toddler with vomiting, abdominal pain, and alopecia.

A previously healthy toddler presented to the emergency department with nonspecific gastrointestinal complaints. Laboratory studies were consistent with pancreatitis, and imaging studies demonstrated a pancreatic transection. Alopecia felt to be related to traction was also noted. There was no history of any witnessed trauma, and nonaccidental trauma was diagnosed.

Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma.

Subconjunctival hemorrhages in infants and children can be a finding after nonaccidental trauma. We describe 14 children with subconjunctival hemorrhages on physical examination, who were subsequently diagnosed by a child protection team with physical abuse. Although infrequent, subconjunctival hemorrhage may be related to abuse. Nonaccidental trauma should be on the differential diagnosis of subconjunctival hemorrhage in children, and consultation with a child abuse pediatrics specialist should be considered.

Healing of genital injuries.

Child sexual abuse as well as accidental trauma may cause acute injuries in the anogenital area. Most data on residual findings following genital trauma come from longitudinal studies of children who have been sexually assaulted, undergone surgical procedures, or experienced accidental trauma. Like injuries in other part parts of the body, such injuries undergo a predictable pattern of healing. Most superficial injuries heal without any residual evidence. Deeper injuries, as well as those that become infected or experience repeated disruption, may produce permanent changes. While the presence of such changes supports allegations of prior anogenital trauma, their absence does not preclude the trauma from having occurred.

COVID-19: Differences in sentinel injury and child abuse reporting during a pandemic.

BACKGROUND AND OBJECTIVES: There is widespread concern that the COVID-19 pandemic has increased the incidence of child maltreatment. However, reports in the scientific literature documenting rates of child maltreatment during this period are scarce. This study was designed to explore whether the incidence of child maltreatment among patients presenting to a pediatric emergency department has increased during the COVID-19 pandemic. METHODS: We conducted a retrospective review of patients of all ages presenting to a pediatric Emergency Department trauma center, who also had a child abuse report filing or a sentinel injury diagnosis related to their index visit. All such patients who presented to this institution from March through July of 2017 through 2020 were included in the study. RESULTS: Analysis demonstrated an increase in the incidence of child maltreatment in May and June of 2020 and that there was an overall shift in distribution of types of child maltreatment during the COVID-19 pandemic. There was a significant increase in the proportion of emotional/psychological abuse (2.52 % before the pandemic to 7.00 % during the pandemic, p ≤ 0.0001) and non-medical neglect (31.5%-40.0%, p ≤ 0.0001). CONCLUSIONS: We observed an increase in specific types of child maltreatment during the COVID-19 pandemic. These findings highlight the need for increased attention to children at risk for child abuse and neglect.

The choking game: a cause of unintentional strangulation.

A 12-year-old girl was brought to the pediatric emergency department by ambulance after her mother found her hanging from her bunk bed. The patient was resuscitated initially but died 5 days later after support was withdrawn. A sexual assault examination was performed, and the finding was negative. The case was investigated as a possible homicide or suicide. Upon questioning relatives, it was disclosed that the deceased had played the choking game. No one knew she had been playing the game alone. The choking game is popular with adolescents and is particularly dangerous when played alone. Emergency physicians should be aware of the characteristic warning signs that include frequent severe headaches, altered mental status after spending time alone, neck markings, and bloodshot eyes and counsel adolescents about the real risks associated with the activity. Accident, suicide, homicide, autoerotic behavior, and the "choking game" should be considered in the differential when an adolescent presents with evidence of strangulation.

Ethical Testimony in Cases of Suspected Child Maltreatment: The Ray E. Helfer Society Guidelines.

New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.

Food insecurity and risk of poor health among US-born children of immigrants.

OBJECTIVES: We investigated the risk of household food insecurity and reported fair or poor health among very young children who were US citizens and whose mothers were immigrants compared with those whose mothers had been born in the United States. METHODS: Data were obtained from 19,275 mothers (7216 of whom were immigrants) who were interviewed in hospital-based settings between 1998 and 2005 as part of the Children's Sentinel Nutrition Assessment Program. We examined whether food insecurity mediated the association between immigrant status and child health in relation to length of stay in the United States. RESULTS: The risk of fair or poor health was higher among children of recent immigrants than among children of US-born mothers (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.02, 1.55; P < .03). Immigrant households were at higher risk of food insecurity than were households with US-born mothers. Newly arrived immigrants were at the highest risk of food insecurity (OR = 2.45; 95% CI = 2.16, 2.77; P < .001). Overall, household food insecurity increased the risk of fair or poor child health (OR = 1.74; 95% CI = 1.57, 1.93; P < .001) and mediated the association between immigrant status and poor child health. CONCLUSIONS: Children of immigrant mothers are at increased risk of fair or poor health and household food insecurity. Policy interventions addressing food insecurity in immigrant households may promote child health.

Professional medical associations and their relationships with industry: a proposal for controlling conflict of interest.

Professional medical associations (PMAs) play an essential role in defining and advancing health care standards. Their conferences, continuing medical education courses, practice guidelines, definitions of ethical norms, and public advocacy positions carry great weight with physicians and the public. Because many PMAs receive extensive funding from pharmaceutical and device companies, it is crucial that their guidelines manage both real and perceived conflict of interests. Any threat to the integrity of PMAs must be thoroughly and effectively resolved. Current PMA policies, however, are not uniform and often lack stringency. To address this situation, the authors first identified and analyzed conflicts of interest that may affect the activities, leadership, and members of PMAs. The authors then went on to formulate guidelines, both short-term and long-term, to prevent the appearance or reality of undue industry influence. The recommendations are rigorous and would require many PMAs to transform their mode of operation and perhaps, to forgo valuable activities. To maintain integrity, sacrifice may be required. Nevertheless, these changes are in the best interest of the PMAs, the profession, their members, and the larger society.

Cutaneous signs of child abuse.

UNLABELLED: Maltreatment of children is a major public health crisis, and it is estimated that each year more than 3 million children are victims of abuse. Safeguarding the welfare of children is a priority, and it is the moral and ethical responsibility of healthcare professionals to detect cases of abuse and intervene appropriately to prevent further harm. Clinicians are often challenged to differentiate signs of child abuse from skin conditions that mimic maltreatment. Because cutaneous injury represents the most recognizable and common form of abuse, dermatologists are often called upon to help distinguish signs of intentional injury from skin conditions that mimic maltreatment. However, few resources specific to dermatologic signs of abuse exist to aid in diagnosis. A review of the literature will provide an educational resource to assist dermatologists and other clinicians in differentiating cutaneous signs of child abuse, including physical and sexual abuse, from mimickers of inflicted injury. LEARNING OBJECTIVE: After completing this learning activity, participants should be able to distinguish signs of intentional injury from skin conditions that mimic maltreatment and understand the clinician's role in the diagnosis and reporting of cases of suspected child abuse.

Breastfeeding and health outcomes among citizen infants of immigrant mothers.

OBJECTIVE: To examine the associations between breastfeeding and child health outcomes among citizen infants of mothers immigrant to the United States. DESIGN/METHODS: From September 1998 through June 2004, as part of the Children's Sentinel Nutrition Assessment Program, a sentinel sample of 3,592 immigrant mothers with infants aged 0 to 12 months were interviewed in emergency departments or pediatric clinics in six sites. Mothers reported breastfeeding history, child health history, household demographics, government assistance program participation, and household food security. Infants' weight and length were recorded at the time of visit. Bivariate analyses identified confounders associated with breastfeeding and outcomes, which were controlled in logistic regression. Additional logistic regressions examined whether food insecurity modified the relationship between breastfeeding and child outcomes. RESULTS: Eighty-three percent of infants of immigrants initiated breastfeeding. Thirty-six percent of immigrant households reported household food insecurity. After controlling for potential confounding variables, breastfed infants of immigrant mothers were less likely to be reported in fair/poor health (adjusted odds ratio [AOR] 0.65, 95% confidence interval [CI] 0.50 to 0.85; P=0.001) and less likely to have a history of hospitalizations (AOR 0.72, CI 0.56 to 0.93, P=0.01), compared to nonbreastfed infants of immigrant mothers. Compared to nonbreastfed infants, the breastfed infants had significantly greater weight-for-age z scores (0.185 vs 0.024; P=0.006) and length-for-age z scores (0.144 vs -0.164; P<0.0001), but there was no significant difference in risk of overweight (weight-for-age >95th percentile or weight-for-length >90th percentile) between the two groups (AOR 0.94, CI 0.73 to 1.21; P=0.63). Household food insecurity modified the association between breastfeeding and child health status, such that the associations between breastfeeding and child health were strongest among food-insecure households. CONCLUSIONS: Breastfeeding is associated with improved health outcomes for infants of immigrant mothers. Breastfeeding is an optimal strategy in the first year of life to improve all infants' health and growth, especially for children of immigrants who are at greater risk for experiencing food insecurity.

Subsidized housing and children's nutritional status: data from a multisite surveillance study.

BACKGROUND: A critical shortage of affordable housing for low-income families continues in the United States. Children in households that are food insecure are at high risk for adverse nutritional and health outcomes and thus may be more vulnerable to the economic pressures exerted by high housing costs. Only about one fourth of eligible families receive a federally financed housing subsidy. Few studies have examined the effects of such housing subsidies on the health and nutritional status of low-income children. OBJECTIVE: To examine the relationship between receiving housing subsidies and nutritional and health status among young children in low-income families, especially those that are food insecure. DESIGN: Cross-sectional observational study. SETTING AND PARTICIPANTS: From August 1998 to June 2003, the Children's Sentinel Nutrition Assessment Program interviewed caregivers of children younger than 3 years in pediatric clinics and emergency departments in 6 sites (Arkansas, California, Maryland, Massachusetts, Minnesota, and Washington, DC). Interviews included demographics, perceived child health, the US Household Food Security Scale, and public assistance program participation. Children's weight at the time of the visit was documented. The study sample consisted of all renter households identified as low income by their participation in at least 1 means-tested program. MAIN OUTCOME MEASURES: Weight for age, self-reported child health status, and history of hospitalization. RESULTS: Data were available for 11 723 low-income renter families; 27% were receiving a public housing subsidy, and 24% were food insecure. In multivariable analyses, stratified by household food security status and adjusted for potential confounding variables, children of food-insecure families not receiving housing subsidies had lower weight for age (adjusted mean z score, -0.025 vs 0.205; P<.001) compared with children of food-insecure families receiving housing subsidies. Compared with children in food-insecure, subsidized families, the adjusted odds ratio (95% confidence interval) for weight-for-age z score more than 2 SDs below the mean was 2.11 (1.34-3.32) for children in food-insecure, nonsubsidized families. CONCLUSIONS: In a large convenience sentinel sample, the children of low-income renter families who receive public housing subsidies are less likely to have anthropometric indications of undernutrition than those of comparable families not receiving housing subsidies, especially if the family is not only low income but also food insecure.