A Longitudinal Study of Health Care Utilization Among Infants Investigated for Maltreatment.

OBJECTIVE: To evaluate whether maltreatment investigated during infancy affects high-acuity health care utilization patterns during early childhood. METHODS: Retrospective case-control study based on linked data between child protection and hospital encounter records conducted to review health records of infants investigated for abuse and/or neglect. Cases and controls were followed longitudinally through the Rady Children's Hospital electronic health records for 4 years starting at the age of 1 year. RESULTS: A total of 3692 children were investigated for maltreatment within the first year of life. When comparisons were made between children reported for maltreatment and matched controls, children with infancy maltreatment reports had significantly more high-acuity health care encounters than matched controls (average treatment effect = 1.53, 95% Confidence Interval 1.08-1.99, P < .001). CONCLUSIONS: Infants investigated for maltreatment have greater high-acuity health care utilization in early childhood. These findings highlight this population's need for well-defined medical homes to ensure appropriate health care. Further understanding of the underlying reasons for this increased health care burden will help inform these efforts.

Accidental and Abusive Mandible Fractures in Infants and Toddlers.

OBJECTIVE: Mandible fractures are uncommon injuries in infants and young children and may raise concern for nonaccidental trauma. Our study describes several children with mandible fractures to identify features that might differentiate abuse from accident. METHODS: Records and imaging were reviewed for children aged 24 months and younger who were diagnosed with mandible fractures at 2 tertiary pediatric care centers. Twenty-one cases were included, 8 of whom had formal child abuse consultations. Cases were reviewed for mechanisms of injury, physical examination findings, and occult injuries identified, as well as the final abuse determination. RESULTS: Among children with child abuse consultations, 5 injuries (62.5%) were determined to be accidental, 1 (12.5%) was abusive, and 2 were indeterminate for abuse or accident (25%). In each accidentally injured child, the reported mechanism of injury was a short fall with evidence of facial impact. No accidentally injured child had unexpected occult injuries or noncraniofacial cutaneous injuries. CONCLUSIONS: Infants and young children can sometimes sustain mandible fractures accidentally after well-described short falls with evidence of facial impact. Abuse remains in the differential diagnosis, and children should be evaluated accordingly. We propose that accidental injury be considered when a well-evaluated child with an isolated mandible fracture has a history of a short fall.

Medical Child Welfare Task Force: A Multidisciplinary Approach to Identifying Medical Child Abuse.

Medical child abuse is a complex form of maltreatment with powerful and long-lasting impacts on the overall health of affected children. The complexity of this condition renders it challenging for clinicians to recognize its presence and intervene appropriately. The failure of medical systems to identify and deescalate care in this form of maltreatment can result in grievous patient harm. Although the medical literature provides limited guidance on how to address these multifaceted cases, several studies advocate for a multidisciplinary approach. Following a severe and chronic case of medical child abuse at our institution, deficits in response became clear within our hospital system. In reaction to these gaps, the Medical Child Welfare Task Force was developed to formalize education and multidisciplinary collaboration around medical child abuse. The support of institutional leadership and the involvement of multiple medical disciplines that commonly encounter these patients was vital to the implementation and long-term success of the endeavor. To facilitate case identification, education was provided to clinicians in a variety of forums. Moreover, we leveraged the electronic medical record to streamline our ability to monitor cases of medical child abuse and communicate the concerns and plan of care to other providers, both within and outside of our health system. A postimplementation survey determined that the establishment of a multidisciplinary team increased provider comfort and skill in identifying and managing cases of suspected medical child abuse.