A validated Screening instrument for Child Abuse and Neglect (SCAN) at the emergency department.

The objective of this study is to develop and validate a screening instrument for the recognition of child maltreatment in the emergency department (ED). Existing data on screening questions and outcomes (diagnosis of child maltreatment) from three large observational screening studies at eight different EDs in the Netherlands were harmonized. A multivariate logistic regression was performed to develop the Screening instrument for Child Abuse and Neglect (SCAN). The SCAN was validated by performing a cross-validation and calculating the discriminative ability. A total of 24,963 patients were included. Out of the potential screening questions the following questions were included in the final instrument: is the injury compatible with the history, and does it correspond to the child's developmental level? (aOR 10.40, 95% CI 5.69-19.02), was there an unnecessary delay in seeking medical help? (aOR 3.45, 95% CI 1.73-6.88) and is the behaviour/interaction of the child and parents (carers) appropriate? (aOR 14.67, 95% CI 7.93-27.13). The SCAN had a pooled AUC of 0.75 (95% CI 0.63-0.87) in the cross-validation. The question "Are there other signals that make you doubt the safety of the child and/or family?" (available in only one of the original datasets, OR 182.9; 95% CI 102.3-327.4) was by consensus added to the final SCAN. CONCLUSION: This validated and brief Screening instrument for Child Abuse and Neglect (SCAN) is designed to improve early recognition of child maltreatment in the ED. A positive screening result of the SCAN warrants a thorough work-up for child maltreatment, including a top-toe examination, if necessary additional diagnostics and adequate safety measures. WHAT IS KNOWN: • Screening instruments increase the detection of possible cases of child maltreatment in the emergency department and support health care professionals to identify these cases. • The application of different screening instruments led to the need for one brief validated instrument. WHAT IS NEW: • This study presents a validated and brief Screening instrument for Child Abuse and Neglect (SCAN), consisting of four questions. • The SCAN supports professionals in detecting signals of child maltreatment, and a positive screening result should lead to a thorough work-up, including a top-toe examination, complete history, additional diagnostic tests and consultation of a child abuse expert.

Does a serious game increase intrinsic motivation in children receiving urotherapy?

INTRODUCTION: Urotherapy is considered the treatment of choice for children suffering daytime urinary incontinence (DUI). Urotherapy intends to improve bladder dysfunction for children with DUI. For children with refractory DUI, an intensive inpatient bladder training program exists, which focuses on relearning, concentration on, and awareness of the bladder. Children's motivation and adherence are key determinants of a successful training outcome. It is hypothesized that motivation endurance throughout the treatment process may be enhanced by a serious game training tool, which could make the training more appealing and rewarding. OBJECTIVE: The study explores intrinsic motivation in children receiving bladder training for DUI and whether using a serious game improves their intrinsic motivation. STUDY DESIGN: In this pragmatic study, 50 children were allowed to choose among receiving bladder training with (intervention group) or without the application of a serious game (control group). At 4, 8, and 12 weeks of training, children and parents were asked to complete the Intrinsic Motivation Inventory (IMI). Children also completed the Pediatric Urinary Incontinence Quality of Life Tool (PinQ) before the start of the training and 6 months thereafter. At 6-month follow-up, patients were ask to participate in two focus groups, wherein the children discussed how they used the serious game and which improvements they would prefer. RESULTS: Children who received standard bladder training with the addition of a serious game did not differ in terms of intrinsic motivation from children who underwent standard bladder training only. Training results were equal in both the groups, with 80% good or improved. Incontinence-related quality of life (QoL) improved accordingly. DISCUSSION: In contrast to the study expectations, this game did not increase intrinsic motivation. Findings on training and QoL results are consistent with those of previous studies in both interventions. Although a randomized design could have yielded more valid results than this preference-based approach, the latter is more congruent with clinical practice. In contrast to existing bladder diary apps, this game offers a combination of child-friendly instructions, explanation of bladder (dys)function, and keeping a bladder diary. Mobile devices are playing an increasingly important role in health care; therefore, an urotherapy app can be a complementary therapeutic tool. CONCLUSION: Most children find it attractive to combine bladder training with a serious game. However, no added value was found regarding intrinsic motivation and training results. All children with persistent DUI in this cohort were highly motivated to complete an intensive bladder training program.

Neuroendocrine dysregulations in sexually abused children and adolescents: a systematic review.

Several studies provided evidence for neuroendocrine dysregulations in adults with a history of child sexual abuse. This review focuses on neuroendocrine studies in sexually abused children and adolescents, dating from January 1, 1990 to January 1, 2007 and obtained from a systematic Medline Indexed literature search to identify endocrine correlates of child sexual abuse. Results from studies on hypothalamic-pituitary-adrenal axis (re)activity showed to be inconclusive. Studies on the sympathetic nervous system provided evidence for a higher baseline activity of this system in sexually abused children and adolescents. Factors contributing to divergent outcomes will be discussed and suggestions for future research will be presented.

[Report of the Dutch National Health Council on chronic fatigue syndrome]. / GR-rapport over chronische-vermoeidheidssyndroom.

In our opinion, the recent report of the Dutch National Health Council on myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) lacks balance: it is very critical on the quality of evidence regarding behavioural interventions, but lacks a critical attitude regarding the presumed somatic components of the disorder. Without solid evidence, the report coins ME/CFS as a severe multisystem disease, and it embraces the diagnostic criteria of the American Institute of Medicine. We underscore the remarks in the report that physicians should not be reluctant to make diagnosis in patients with the disorder, and that these patients should be approached with empathy and respect. Regarding a future research programme, there is need for a well-designed research agenda.

No evidence found for an increased risk of long-term fatigue following human papillomavirus vaccination of adolescent girls.

INTRODUCTION: In 2013, the Netherlands Pharmacovigilance Center Lareb published an overview of reports of long-lasting fatigue following bivalent HPV-vaccination (2vHPV). After an update of this overview in 2015, concerns regarding the safety of 2vHPV was picked up by the media, which led to further reports of long-lasting fatigue. Therefore, the Dutch National Institute for Public Health and the Environment (RIVM) investigated a possible association between HPV-vaccination and long-term fatigue. METHODS: In this retrospective cohort study conducted in the Integrated Primary Care Information database, we investigated the occurrence of chronic fatigue syndrome (CFS), fatigue ≥6 months and 3-6 months in all girls born in 1991-2000 during the follow-up period January 1st 2007-December 31st 2014 (2007-2008 pre-vaccination and 2009-2014 post-vaccination). Patients with certain fatigue ≥6 m were asked for consent to link their primary care information with vaccination data. Incidence rates per 10,000 person years (PY) for 12-16-year-old girls were compared between pre- and post-HPV-vaccine era. A self-controlled case series (SCCS) analysis was performed using consenting vaccinated cases. A primary high-risk period of 12 months after each dose was defined. RESULTS: The cohort consisted of 69,429 12-16-year-old girls accounting for 2758 PY pre-vaccination and 57,214 PY post-vaccination. Differences between pre- and post-vaccination incidences (CFS: 3.6 (95% CI 0.5-25.7)/10,000 PY and 0.9 (0.4-2.1); certain fatigue ≥6 m: 7.3 (1.8-29.0) and 19.4 (16.1-23.4); certain fatigue 3-6 m: 0.0 and 16.6 (13.6-20.3), respectively) were not statistically significant. SCCS analyses in 16 consenting vaccinated cases resulted in an age-adjusted RR of 0.62 (95%CI 0.07-5.49). CONCLUSIONS: Fatigue ≥6 m and 3-6 m was frequently found among adolescent girls, but CFS was rarely diagnosed. No statistically significant increased incidence rates were found post-vaccination compared to similar age groups of girls pre-vaccination. The SCCS analysis included a low number of cases but revealed no elevated risk of certain fatigue ≥6 m in the high-risk period.

[The use of complementary and alternative medicine in children at a general paediatric clinic and parental reasons for use]. / Het gebruik van complementaire en alternatieve geneeswijzen door kinderen op een polikliniek voor kindergeneeskunde en de redenen van ouders daarvoor.

OBJECTIVE: To determine the prevalence of and reasons for the use of complementary and alternative medicine (CAM) in paediatric patients, and to determine the parental need for appropriate information from their paediatrician. DESIGN: Questionnaire. METHOD: A questionnaire was given to the parents of general paediatric patients of the St. Antonius Hospital Nieuwegein and the University Medical Centre Utrecht, the Netherlands, in the period June 2003-March 2004. Parents were asked about CAM use in the past 12 months, which CAM modalities were used and their reasons for using it. They were also asked about their need to receive information on CAM from their paediatrician. RESULTS: A total of 581 of 617 parents completed the questionnaire (94%). CAM was used by 177 (30%) patients. The most frequently used types of CAM were homeopathy (48%), phytotherapy (45%), nutritional supplements (28%) and manual therapies (28%). CAM was used most often in children with headache or chronic fatigue. The most frequently cited reasons for CAM use were a desire for the child to feel better and a preference for a 'more natural' therapy. Factors associated with CAM use were a high level of parental education and use of CAM by the parent. Only 40% of parents had reported the use of CAM to their paediatrician, usually on their own initiative. The majority of the parents (60%) found it important to very important that the paediatrician is able to provide information on CAM. CONCLUSION: Almost one-third of patients visiting a general paediatrician had used complementary or alternative medicine in the past year. Given the possible interactions with conventional therapies and the desire of parents to receive more information on CAM, paediatricians should expand the patient history assessment to include questions regarding the use of CAM.

[An integrated approach including paediatric and forensic medical expertise on suspicion of child abuse]. / Meer zekerheid bij vermoeden van kindermishandeling.

A false accusation of child abuse has a major impact on child and family. Conversely, a missed diagnosis of child abuse may have significant and lifelong consequences for the child. For health professionals the assessment of the nature of the injury and differentiating between accidental and inflicted injury, disease manifestation or a physiological phenomenon can be challenging. For adequate determination of the cause of injury, an integrated approach including paediatric knowledge and forensic medical expertise is essential. Therefore, a national expertise centre for child abuse (LECK) was established in the Netherlands in 2014. The first results of this integrated approach are described and illustrated with three case reports. Case A, a 7-month-old boy with an accidental humerus fracture. Case B, an 8-year-old boy with a false positive suspicion of child abuse who was eventually diagnosed with Henoch-Schönlein syndrome. Case C, boy of 3 months with bruises and a metaphyseal fracture of the femur, both highly suspected of being inflicted injury.

[Systematic detection of physical child abuse at emergency rooms]. / Screening op kindermishandeling op de SEH.

OBJECTIVE: The aim of our diagnostic accuracy study Child Abuse Inventory at Emergency Rooms (CHAIN-ER) was to establish whether a widely used checklist accurately detects or excludes physical abuse among children presenting to ERs with physical injury. DESIGN: A large multicentre study with a 6-month follow-up in 4 ERs in The Netherlands. METHOD: Participants were 4290 children aged 0-7 years, attending the ER because of physical injury. All children were systematically tested with an easy-to-use child abuse checklist (index test). A national expert panel (reference standard) retrospectively assessed all children with positive screens and a 15% random sample of the children with negative screens for physical abuse, using additional information, namely, an injury history taken by a paediatrician, information provided by the general practitioner, youth doctor and social services by structured questionnaires, and 6-month follow-up information. Our main outcome measure was physical child abuse; secondary outcome measure was injury due to neglect and need for help. RESULTS: 4253/4290 (99%) parents agreed to follow-up. At a prevalence of 0.07% (3/4253) for inflicted injury by expert panel decision, the positive predictive value of the checklist was 0.03 (95% CI 0.006 to 0.085), and the negative predictive value 1.0 (0.994 to 1.0). There was 100% (93 to 100) agreement about inflicted injury in children, with positive screens between the expert panel and child abuse experts. CONCLUSION: Rare cases of inflicted injury among preschool children presenting at ERs for injury are very likely captured by easy-to-use checklists, but at very high false-positive rates. Subsequent assessment by child abuse experts can be safely restricted to children with positive screens at very low risk of missing cases of inflicted injury. Because of the high false positive rate, we do advise careful prior consideration of cost-effectiveness and clinical and societal implications before de novo implementation.

Successful e-learning programme on the detection of child abuse in emergency departments: a randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of an electronic learning (e-learning) programme on the performance of nurses in the recognition of child abuse in a simulated case in the Emergency Department (ED). DESIGN: Blinded, randomised controlled trial using pre- and postintervention design. SETTING: The ED of a University Medical Center in the Netherlands. PARTICIPANTS: 38 ED nurses were included, 25 nurses were analysed. INTERVENTION: Half of the participants followed a 2-hour e-learning programme focused on the recognition of child abuse, the others acted as a control group. MAIN OUTCOME MEASUREMENTS: Individual performance during a case-simulated parent interview to detect child abuse and self-reported self-efficacy for the detection of child abuse. Performance on the simulation was scored by an expert panel using a standardised assessment form which was designed to score quantity and quality of the questions posed by the nurse (minimum score 0; maximum score 114). RESULTS: During post-test, nurses in the intervention group performed significantly better during the simulation than the control group, (89 vs 71, 95% CI 2.9 to 33.3), and reported higher self-efficacy (502 vs 447, 95% CI -25.4 to 134.7). Performance in detecting child abuse correlated positively with the self-efficacy score (Spearman correlation 0.387, p value 0.056). Comparing post- and pretest results separately for the intervention and the control group showed a significant increase in performance in the intervention group. CONCLUSION: E-learning improved the performance in case simulations and the self-efficacy of the nurses in the ED in the detection of child abuse. Wider implementation of the e-learning programme to improve the first step in the detection of child abuse is recommended.

How fatigue is related to other somatic symptoms.

AIMS: To assess the relation between fatigue and somatic symptoms in healthy adolescents and adolescents with chronic fatigue syndrome/myalgic encephalopathy (CFS/ME). METHODS: Seventy two adolescents with CFS were compared within a cross-sectional study design with 167 healthy controls. Fatigue and somatic complaints were measured using self-report questionnaires, respectively the subscale subjective fatigue of the Checklist Individual Strength (CIS-20) and the Children's Somatization Inventory. RESULTS: Healthy adolescents reported the same somatic symptoms as adolescents with CFS/ME, but with a lower score of severity. The top 10 somatic complaints were the same: low energy, headache, heaviness in arms/legs, dizziness, sore muscles, hot/cold spells, weakness in body parts, pain in joints, nausea/upset stomach, back pain. There was a clear positive relation between log somatic symptoms and fatigue (linear regression coefficient: 0.041 points log somatic complaints per score point fatigue, 95% CI 0.033 to 0.049) which did not depend on disease status. CONCLUSIONS: Results suggest a continuum with a gradual transition from fatigue with associated symptoms in healthy adolescents to the symptom complex of CFS/ME.

Is chronic fatigue syndrome a connective tissue disorder? A cross-sectional study in adolescents.

OBJECTIVES: To investigate whether constitutional laxity of the connective tissues is more frequently present in adolescents with chronic fatigue syndrome (CFS) than in healthy controls. Increased joint hypermobility in patients with CFS has been previously described, as has lower blood pressure in fatigued individuals, which raises the question of whether constitutional laxity is a possible biological predisposing factor for CFS. DESIGN: Cross-sectional study. PARTICIPANTS: Thirty-two adolescents with CFS (according to the criteria of the Centers for Disease Control and Prevention) referred to a tertiary hospital and 167 healthy controls. METHODS: The 32 adolescents with CFS were examined extensively regarding collagen-related parameters: joint mobility, blood pressure, arterial stiffness and arterial wall thickness, skin extensibility, and degradation products of collagen metabolism. Possible confounding factors (age, gender, height, weight, physical activity, muscle strength, diet, alcohol consumption, and cigarette smoking) were also measured. The results were compared with findings in 167 healthy adolescents who underwent the same examinations. RESULTS: Joint mobility, Beighton score, and collagen biochemistry, all indicators of connective tissue abnormality, were equal for both groups. Systolic blood pressure, however, was remarkably lower in patients with CFS (117.3 vs. 129.7 mm Hg; adjusted difference: -13.5 mm Hg; 95% confidence interval [CI]: -19.1, -7.0). Skin extensibility was higher in adolescents with CFS (mean z score: 0.5 vs. 0.1 SD; adjusted difference: 0.3 SD; 95% CI: 0.1, 0.5). Arterial stiffness, expressed as common carotid distension, was lower in adolescents with CFS, indicating stiffer arteries (670 vs 820 mum; adjusted difference: -110 mum; 95% CI: -220, -10). All analyses were adjusted for age, gender, body mass index, and physical activity. Additionally, arterial stiffness was adjusted for lumen diameter and pulse pressure. CONCLUSIONS: These findings do not consistently point in the same direction of an abnormality in connective tissue. Patients with CFS did have lower blood pressure and more extensible skin but lacked the most important parameter indicating constitutional laxity, ie, joint hypermobility. Moreover, the collagen metabolism measured by crosslinks and hydroxyproline in urine, mainly reflecting bone resorption, was not different. The unexpected finding of stiffer arteries in patients with CFS warrants additional investigation.

Chronic fatigue syndrome and health control in adolescents and parents.

AIMS: To explore the locus of health control in adolescents with chronic fatigue syndrome (CFS) and their parents in comparison with healthy adolescents and their parents. METHODS: In this cross-sectional study 32 adolescents with CFS were compared with 167 healthy controls and their respective parents. The Multidimensional Health Locus of Control (MHLC) questionnaire was applied to all participants. RESULTS: There was significantly less internal health control in adolescents with CFS than in healthy controls. An increase of internal health control of one standard deviation was associated with a 61% reduced risk for CFS (OR = 0.39, 95% CI 0.25 to 0.61). Internal health control of the parents was also protective (OR fathers: 0.57 (95% CI 0.38 to 0.87); OR mothers: 0.74 (95% CI 0.50 to 1.09)). The external loci of health control were higher in adolescents with CFS and in their parents. Increased levels of fatigue (56%) were found in the mothers of the adolescents with CFS, in contrast with the fathers who reported a normal percentage of 13. CONCLUSIONS: In comparison with healthy adolescents, adolescents with CFS and their parents show less internal health control. They attribute their health more to external factors, such as chance and physicians. This outcome is of relevance for treatment strategies such as cognitive behaviour therapy, for which health behaviour is the main focus.

Retinopathy following measles, mumps, and rubella vaccination in an immuno-incompetent girl.

We describe a 4-year-old girl with subnormal visual acuity due to a bilateral retinopathy. The child had a history of encephalitis following MMR vaccination. Temporary retinopathy associated with measles, mumps, and rubella (MMR) vaccination has been described. Recently an idiopathic CD4+ T lymphocytopenia in the child was diagnosed. This cellular immunodeficiency supports our hypothesis of measles retinopathy after vaccination of an immuno-deficient child.

Fatal encephalitis caused by Mycoplasma pneumoniae in a 9-year-old girl.

A case of fatal encephalitis in a 9-year-old girl is described. Serology showed high titre antibodies against Mycoplasma pneumoniae. In addition M. pneumoniae was detected in cerebrospinal fluid by polymerase chain reaction. Direct invasion of the central nervous system as opposed to a secondary immunologic reaction to a M. pneumoniae infection of the respiratory tract in the pathogenesis of encephalitis is discussed.