The Pediatrician's Role in Preventing Child Maltreatment: Clinical Report.

Pediatricians have always seen the value of preventing health harms; this should be no less true for child maltreatment than for disease or unintentional injuries. Research continues to demonstrate that maltreatment can be prevented, underscoring the vital roles of both the family and society in healthy childhood development and the importance of strong, stable, nurturing relationships in preventing maltreatment and building the child's resilience to adversity. This clinical report elaborates the pediatrician's multitiered role in supporting relational health from infancy through adolescence, from universal interventions assessing for maltreatment risks and protective factors to targeted interventions addressing identified needs and building on strengths. When maltreatment has already occurred, interventions can prevent further victimization and mitigate long-term sequelae. Advice is provided on engaging community resources, including those that provide food, shelter, or financial support for families in need.

Epidemiologic Analysis of a Postelimination Measles Outbreak in Central Ohio, 2022-2023.

Importance: Postelimination outbreaks threaten nearly a quarter century of measles elimination in the US. Understanding these dynamics is essential for maintaining the nation's measles elimination status. Objective: To examine the demographic characteristics and transmission dynamics of the 2022 to 2023 central Ohio measles outbreak. Design, Setting, and Participants: This cross-sectional study used electronic medical records and publicly available measles reports within an extensive central Ohio primary care network involving inpatient and outpatient settings. Participants included 90 children in Ohio with confirmed measles cases in 2022. Exposure: The exposure of interest was confirmed measles cases in Ohio in 2022. This included 5 internationally imported cases and 85 locally acquired cases. Main Outcomes and Measures: The primary outcome involved documenting and analyzing confirmed measles cases in Ohio in 2022, focusing on demographic characteristics, immunization status, and transmission links in outbreak-related cases. Results: This study analyzed 90 measles cases (47 [52.2%] male participants) in Ohio during 2022. Most participants self-identified as African or American Black (72 [80.0%]), with additional race categories including Asian, Hispanic, multirace (6 [6.7%]), White, and unknown (6 [6.7%]). Most participants were of Somali descent (64 [71.1%]), with additional ethnicity categories including American (16 [17.8%]), Guatemalan, Nepali, and unknown (6 [6.7%]). Participants were predominantly younger than 6 years (86 [95.5%]), unimmunized (89 [98.9%]), and resided in Franklin County, Ohio (83 [92.2%]). Prior to November 20, 2022, all cases occurred among unimmunized children of Somali descent in the Columbus area. Nosocomial superspreading events expanded the outbreak beyond the initially affected community. Conclusions and Relevance: This cross-sectional study of measles cases in Ohio during 2022 found that the outbreak primarily affected unimmunized children of Somali descent, highlighting the necessity for culturally tailored public health strategies to maintain measles elimination in the US. These findings underscore the importance of implementing targeted interventions and enhancing community engagement to increase vaccination rates.

Predictors of Corporal Punishment during the COVID-19 Pandemic.

Although current policies discourage the use of corporal punishment (CP), its use is still widespread in the US. The objective of this study was to assess the proportion of parents who used CP during the pandemic and identify related risk and protective factors. We analyzed results of a nationwide cross-sectional internet panel survey of 9000 US caregivers who responded in three waves from November 2020 to July 2021. One in six respondents reported having spanked their child in the past week. Spanking was associated with intimate partner violence and the use of multiple discipline strategies and not significantly associated with region or racial self-identification. Parents who spanked sought out more kinds of support, suggesting an opportunity to reduce spanking through more effective parenting resources. Additionally, these results suggest that parents who report using CP may be at risk for concurrent domestic violence.

Evidence-based health care for children: what are we missing?

With the enactment of comprehensive health reform, reimbursement for a variety of health care services will likely depend on evidence to support that provision. Understanding what constitutes "evidence" will have a profound effect on the range of clinical care provided. A too-narrow definition may have a considerable impact on pediatric care in particular: much of current child health care requires consideration of a broader body of evidence than is usually relied upon when developing clinical guidelines. This is especially true for care that addresses behavioral and developmental problems. The current standard for evaluating evidence uses study design as a proxy for the quality of evidence; it may therefore inadvertently exclude many important findings and fail to support further relevant research. The project described here yielded a new, broader framework for evaluating clinical practice, one that should be of value to both clinicians and policymakers.

Care for children and evidence-based medicine.

Child healthcare sits between two worlds: in the past, with a focus on the prevention and treatment of infectious and chronic disease and the current more expansive view of child health and our role in child health promotion. As a result, disagreements concerning the evidence basis for our work have also arisen. Clinicians may stay on track by considering multiple sources of evidence in making clinical decisions. In doing so, it helps to consider each activity from the perspective of the child, family, and community. Screening and intervention may look for existing problems, for risk and resilience factors, and for opportunities to optimize each child's developmental potential. Integration of these various concerns underlies the art of modern practice, provides the assistance that families want, and leads to continued professional satisfaction.

Effective Discipline to Raise Healthy Children.

Pediatricians are a source of advice for parents and guardians concerning the management of child behavior, including discipline strategies that are used to teach appropriate behavior and protect their children and others from the adverse effects of challenging behavior. Aversive disciplinary strategies, including all forms of corporal punishment and yelling at or shaming children, are minimally effective in the short-term and not effective in the long-term. With new evidence, researchers link corporal punishment to an increased risk of negative behavioral, cognitive, psychosocial, and emotional outcomes for children. In this Policy Statement, the American Academy of Pediatrics provides guidance for pediatricians and other child health care providers on educating parents about positive and effective parenting strategies of discipline for children at each stage of development as well as references to educational materials. This statement supports the need for adults to avoid physical punishment and verbal abuse of children.

Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment.

Children who have suffered early abuse or neglect may later present with significant health and behavior problems that may persist long after the abusive or neglectful environment has been remediated. Neurobiological research suggests that early maltreatment may result in an altered psychological and physiologic response to stressful stimuli, a response that deleteriously affects the child's subsequent development. Pediatricians can assist caregivers by helping them recognize the abused or neglected child's emotional and behavioral responses associated with child maltreatment and guide them in the use of positive parenting strategies, referring the children and families to evidence-based therapeutic treatment and mobilizing available community resources.

Responding to ACEs With HOPE: Health Outcomes From Positive Experiences.

This article introduces a framework called "HOPE: Health Outcomes From Positive Experiences." The HOPE framework focuses on the need to actively promote positive childhood experiences that contribute to healthy development and well-being, as well as prevent or mitigate the effect of adverse childhood experiences and other negative environmental influences. Key positive childhood experiences fall within 4 broad categories: being in nurturing, supportive relationships; living, developing, playing, and learning in safe, stable, protective, and equitable environments; having opportunities for constructive social engagement and connectedness; and learning social and emotional competencies. The HOPE framework grows out of and complements prior holistic approaches to child health care.

Patient and injury characteristics in abusive abdominal injuries.

OBJECTIVE: To identify patient and injury characteristics associated with suspected child abuse in the setting of blunt abdominal trauma. PATIENTS: We extracted from the National Pediatric Trauma Registry phases 2 and 3 (October 1995 to April 2001; N = 106,135) all cases of blunt abdominal injury, excluding motor vehicle injuries, in patients aged 0 to 4 years. MAIN OUTCOME MEASURES: Independent variables included age, mortality, nutritional status, and injury type. The dependent variable was suspected child abuse. RESULTS: Six hundred sixty-four cases were analyzed. The median age of patients was 2.6 years; 11.4% were undernourished. The 3 most common mechanisms of injury were suspected child abuse (40.5%), fall (36.6%), and struck-not child abuse (9.7%). Hepatic injury (46.1%) was the most common intra-abdominal injury, followed by splenic (26%), hollow viscous (17.9%), and pancreatic (8.6%) injuries. Eighty-four percent of deaths were related to suspected child abuse. There was a greater proportion of children with suspected child abuse in every patient and injury characteristics studied than all other mechanisms combined. In a regression model including age, undernourishment, pancreatic injury, hollow viscous injury, traumatic brain injury, and mortality, all variables were significantly associated with suspected abuse. Hollow viscous injury had the highest odds ratio (OR, 9.5; confidence limits, 5.7, 15.8), whereas traumatic brain injury had the lowest (OR, 3.6; confidence limits, 2.4, 5.6). CONCLUSIONS: Young children with severe pancreatic or hollow viscous injuries or severe abdominal injuries in the context of either brain injury or undernourishment should be evaluated for the possibility that these injuries resulted from abuse. Increasing the awareness of the possibility of child abuse associated with a set of injury characteristics may allow for more consistent and complete medical evaluation.

Bringing violence prevention into the clinic: the Massachusetts Medical Society Violence Prevention Project.

This case study describes the experience of the Massachusetts Medical Society Violence Prevention Program. Beginning in 1996, this program developed materials to support physicians who wanted to incorporate violence prevention into primary care and urgent care practice. With technical assistance from the Harvard Youth Violence Prevention Center, the society produced parent information cards in English and Spanish, a clinical guide, and online training resources. Orders have been received from around the country and from community-based organizations and local governments. The success of this project illustrates the general interest in authoritative and useable violence prevention information.

Pediatric violence-related injuries in Boston: results of a city-wide emergency department surveillance program.

CONTEXT: Violence-related injuries among children are common, but age-based incidence data are not easily available. OBJECTIVES: To describe injuries due to violence in a population-based case series of children and to estimate injury incidence. DESIGN: Prospective surveillance of children residing in Boston, Mass, who received pediatric emergency department treatment for violence-related injury during a 4-year period beginning April 15, 1995. SETTING: Pediatric emergency departments in Boston. PATIENTS: Children aged 3 through 18 years who came to a hospital emergency department between April 1995 and April 1999. Violence-related injuries were defined as those resulting from a situation of conflict involving 2 or more persons with intent to harm, as assessed by health care personnel caring for the patients. Self-inflicted injuries and injuries caused by child abuse (including any injury resulting from a conflict with a parent or guardian) were excluded. Homicides of Boston children aged 3 through 18 years who were killed during the study period were included based on police data. MAIN OUTCOME MEASURE: Population-based violence-related injury rates. RESULTS: There were 2035 injury-related visits caused by violence, which reflects a rate of 52.7 (95% confidence interval, 50.5-54.9) per 10 000 person-years. Most injuries were relatively minor; 6.4% of visits resulted in admission. The youth violence-related injury rate in Boston declined at an average rate of 12% annually during the period studied. CONCLUSION: Pediatric emergency department monitoring of violence-related injury in Boston suggests that childhood injuries due to violence declined during the late 1990s.

Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes.

This study sought to evaluate injury causes and patient outcomes in young children with abdominal injuries. Cases of blunt abdominal injury (N = 927) to children ages 0 to 4 years were extracted from the National Pediatric Trauma Registry. Measures included hospital utilization (days hospitalized, intensive care unit use, and surgery) and patient outcome (in-hospital fatality, discharge to rehabilitation facility, home rehabilitation, and home nursing). The three most common mechanisms of abdominal injury were motor vehicles (61.27%), child abuse (15.75%), and falls (13.59%). Hospital utilization was higher in patients with multisystem injuries. Patient outcomes were more severe in abused children or those with concomitant central nervous system (CNS) injury; these were the only variables independently associated with increased mortality in this sample. Pediatric abdominal trauma leads to intense use of hospital resources and a high risk of in-hospital mortality. Child abuse, compared to falls, is independently associated with a 6-fold increase in in-hospital mortality.

Child abuse physicians: coping with challenges.

This article explores how child abuse physicians (CAPs) experience the unique challenges of the emerging field of child abuse pediatrics. Practicing CAPs completed a written survey about known challenges in their field. Fifty-six CAPs completed the written survey and reported experiencing many negative consequences including: threats to their personal safety (52%), formal complaints to supervisors (50%) and licensing bodies (13%), negative stories in the media (23%), and malpractice suits (16%). A purposeful sample of CAPs participated in telephone interviews about these challenges. The 19 physicians who were interviewed described the challenges, while they spontaneously expressed satisfaction with their career and described some strategies for coping with the stresses of child abuse pediatrics. The findings highlight the stressors and challenges that may affect the ability to maintain an adequate CAP workforce. Better understanding of the challenges should help prepare physicians to practice this subspecialty.