Incidence of Injury, Maltreatment, and Developmental Disorders Among Substance Exposed Infants.

Recent changes to federal legislation created a requirement for states to address the needs of infants with prenatal substance exposure. Understanding clinical outcomes among substance exposed infants prior to these changes is important for establishing a baseline of risk and informing systems-level responses. Using North Carolina, Georgia, and Texas Medicaid data, we examined the incidence of inpatient and outpatient diagnoses for injury, maltreatment, and developmental disorders prior to age 12 months and compared types of diagnoses among substance exposed and unexposed infants. The cumulative incidence of maltreatment (1.2% vs. 0.2%) and developmental disorder (10.7% vs. 1.5%) diagnoses prior to age 12 months was significantly higher among substance exposed compared to unexposed infants. The incidence of injury diagnoses was similar (3.7% vs. 3.4%). We observed differences in types of maltreatment and injury diagnoses. For example, diagnoses for neglect were more common among substance exposed infants while diagnoses for physical abuse were more common among unexposed infants. Results provide insight for informing monitoring and intervention by medical and public health professionals.

Has this prepubertal girl been sexually abused?

CONTEXT: The legal and social sequelae of interpreting genital findings as indicative of sexual abuse are significant. While the absence of genital trauma does not rule out sexual abuse, the physical examination can identify genital findings compatible with sexual abuse. OBJECTIVES: To determine the diagnostic utility of the genital examination in prepubertal girls for identifying nonacute sexual abuse. DATA SOURCES: Published articles (1966-October 2008) that appeared in the MEDLINE database and were indexed under the search terms of child abuse, sexual or child abuse and either physical examination; genitalia; female, diagnosis; or sensitivity and specificity; and bibliographies of retrieved articles and textbooks. STUDY SELECTION: Three of the authors independently reviewed titles of articles obtained from MEDLINE and selected articles for full-text review. DATA EXTRACTION: Two authors independently abstracted data to calculate sensitivity, specificity, and likelihood ratios for the diagnosis of nonacute genital trauma caused by sexual abuse in prepubertal girls. RESULTS: Data were not pooled due to study heterogeneity. The presence of vaginal discharge (positive likelihood ratio, 2.7; 95% confidence interval, 1.2-6.0) indicates an increased likelihood of sexual abuse. In the posterior hymen, hymenal transections, deep notches, and perforations prompt concerns for genital trauma from sexual abuse, but the sensitivity is unknown. Without a history of genital trauma from sexual abuse, the majority of prepubertal girls will not have a hymenal transection (specificity close to 100%). CONCLUSIONS: Vaginal discharge as well as posterior hymenal transections, deep notches, and perforations raise the suspicion for sexual abuse in a prepubertal girl, but the findings do not independently confirm the diagnosis. Given the broad 95% confidence intervals around the likelihood ratios for the presence of findings along with the low or unknown sensitivity of all physical examination findings evaluated, the physical examination cannot independently confirm or exclude nonacute sexual abuse as the cause of genital trauma in prepubertal girls.

Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders.

BACKGROUND: Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT. METHODS: We reviewed subjects <4 years of age in the Universal Data Collection database. ICH was categorized on the basis of association with trauma. Prevalence and probability of types of ICH were calculated for each bleeding disorder. RESULTS: Of 3717 subjects, 255 (6.9%) had any ICH and 206 (5.5%) had nontraumatic ICH. The highest prevalence of ICH was in severe hemophilia A (9.1%) and B (10.7%). Of the 1233 subjects <2 years of age in which the specific location of any ICH was known, 13 (1.1%) had spontaneous SDH (12 with severe hemophilia; 1 with type 1 vWD). The findings in the subject with vWD were not congruent with AHT. CONCLUSIONS: In congenital bleeding disorders, nontraumatic ICH occurs most commonly in severe hemophilia. In this study, vWD is not supported as a "mimic" of AHT.

Accuracy of caregiver identification of developmental delays among young children involved with child welfare.

Underidentification of developmental delays among young children involved with child welfare/child protective services (CW) is problematic. Caregivers of young children involved with CW may help increase identification of young children with developmental delays, but the accuracy of caregiver identification in this population and whether this varies by caregiver type is not known. This study uses data from the National Survey of Child and Adolescent Well-Being to determine if (1) caregivers of young children involved with CW accurately identify children with developmental delays and (2) foster caregivers are better able to identify developmental delays compared with other caregivers. Close to half the children had a delay in language, cognitive, and/or adaptive behavior (45%). Overall sensitivity for caregiver identification was 35% (95% confidence interval [CI]: 29%, 41%); specificity was 84% (95% CI: 80%, 87%). After controlling for certain child and caregiver characteristics, in-home caregivers had 0.15 times the odds of identifying a child with a developmental delay compared with foster caregivers (95% CI 0.1, 0.4). Results suggest that caregiver identification of developmental delays is specific but not sensitive, and that foster caregivers were more likely to identify a child with a developmental delay compared with in-home caregivers. Policy implications include improving educational programs regarding child development and developmental services for foster, kinship, as well as in-home caregivers in the hopes of increasing sensitivity of caregiver identification of developmental delays for the population of young children involved with CW.