RESUMEN
BACKGROUND: Compassion fatigue and burnout are important issues within the medical field, and may be an even bigger problem for Child Abuse Pediatricians (CAPs). While the Accreditation Council for Graduate Medical Education (ACGME) mandates educational activities focused on burnout and resilience, there is currently minimal data to inform the choice and implementation of these activities. OBJECTIVE: Our objectives were to: determine the availability and perceived usefulness of educational activities related to burnout and resilience available in CAP fellowships; and explore the relationship between fellowship activities and burnout. PARTICIPANTS AND SETTING: Surveys were distributed in 2016 to 133 participants in CAP fellowships since 2006. METHODS: Burnout risk was measured using the Maslach Burnout Inventory - Human Services Survey (MBI-HSS). Logistic regression models were used to assess the association of burnout as measured by the MBI-HSS with specific educational activities. RESULTS: Of 133 eligible individuals, 85 (64 %) responded. Of these, 40 (53 %) scored in the high-risk range for at least 1 of the three subscales. Activities perceived to be most useful in addressing burnout were: multidisciplinary team interactions, time spent with the team outside of work, and faculty/trainee one-on-one mentorship. Educational activities were only weakly associated with addressing burnout as measured by the MBI-HSS. CONCLUSIONS: Moderate or high levels of burnout are present in a large proportion of practicing CAPs and more than one-third of participants felt that the quality of burnout training in fellowship did not meet their needs. These data support the need to more effectively address burnout education within the training experience of CAP fellows.
Asunto(s)
Agotamiento Profesional , Maltrato a los Niños , Pruebas Psicológicas , Autoinforme , Niño , Humanos , Becas , Pediatras , Agotamiento Profesional/prevención & control , Encuestas y Cuestionarios , Maltrato a los Niños/prevención & controlRESUMEN
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding that may raise a concern for abuse requires an evaluation for bleeding disorders. However, in some instances, bleeding disorders can present in a manner similar to child abuse. Bleeding disorders cannot be ruled out solely on the basis of patient and family history, no matter how extensive. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
Asunto(s)
Trastornos de la Coagulación Sanguínea , Maltrato a los Niños , Contusiones , Niño , Maltrato a los Niños/diagnóstico , Contusiones/diagnóstico , Contusiones/etiología , Hemorragia/diagnóstico , Hemorragia/etiología , Humanos , PrevalenciaRESUMEN
OBJECTIVE: To replicate the previously published finding that the absence of a history of trauma in a child with obvious traumatic head injuries demonstrates high specificity and high positive predictive value (PPV) for abusive head trauma. STUDY DESIGN: This was a secondary analysis of a deidentified, cross-sectional dataset containing prospective data on 346 young children with acute head injury hospitalized for intensive care across 18 sites between 2010 and 2013, to estimate the diagnostic relevance of a caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma inconsistent with the child's gross motor skills. Cases were categorized as definite or not definite abusive head trauma based solely on patients' clinical and radiologic findings. For each presumptive historical "red flag," we calculated sensitivity, specificity, predictive values, and likelihood ratio (LR) with 95% CI for definite abusive head trauma in all patients and also in cohorts with normal, abnormal, or persistent abnormal neurologic status. RESULTS: A caregiver's specific denial of any trauma demonstrated a specificity of 0.90 (95% CI, 0.84-0.94), PPV of 0.81 (95% CI, 0.71-0.88), and a positive LR (LR+) of 4.83 (95% CI, 3.07-7.61) for definite abusive head trauma in all patients. Specificity and LR+ were lowest-not highest-in patients with persistent neurologic abnormalities. The 2 other historical red flags showed similar trends. CONCLUSIONS: A caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma that is developmentally inconsistent are each highly specific (>0.90) but may provide weaker support than previously reported for a diagnosis of abusive head trauma in patients with persistent neurologic abnormalities.
Asunto(s)
Lesiones Encefálicas/diagnóstico , Maltrato a los Niños/diagnóstico , Traumatismos Craneocerebrales/diagnóstico , Cuidadores , Niño , Preescolar , Estudios Transversales , Interpretación Estadística de Datos , Femenino , Hospitalización , Humanos , Lactante , Recién Nacido , Masculino , Destreza Motora , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
Common intraoral manifestations of child abuse include tears of the frenula, burns, and pharyngeal perforations. Sublingual hematomas can also occur as a result of trauma, but to the best of our knowledge, only 1 case has been previously described in the context of child abuse. We report 2 new cases of sublingual hematoma in infants that were the result of physical abuse. Cases of sublingual hematoma in infants and children without a clear and legitimate explanation of the cause should prompt consideration of child abuse.
Asunto(s)
Maltrato a los Niños , Hematoma/etiología , Enfermedades de la Lengua/etiología , Femenino , Humanos , Lactante , MasculinoRESUMEN
BACKGROUND: Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the pediatric population. We aimed to assess the social and legal outcomes of AHT and determine if the rates of successful prosecution have changed over recent years. METHODS: We utilized the trauma database at a single institution to identify all cases of AHT during two time periods: 1996-2001 and 2006-2010 then collected data from the Child Advocacy and Protection Team database. We characterized the social and legal outcomes and compared them between the two cohorts. RESULTS: A total of 254 patients (120 historic and 134 modern cohort) were included. Mortality rate was 19.7% and did not differ between the two cohorts. Thirty-seven percent of patients were discharged to foster care, this rate did not change across the two time periods. Suspected perpetrators pled guilty or were found guilty in only 74 cases (29%). However, when a case involved a fatality, perpetrators pled or were found guilty more often than in cases of a non-fatality (50 vs. 21.5%; p=0.0001). CONCLUSIONS: AHT results in fatality in approximately 1 in 5 cases, perpetrators are identified and found guilty in only 29% of the cases. Trauma surgeons need to be strong advocates for these vulnerable patients and actively participate in legal proceedings.
Asunto(s)
Maltrato a los Niños/legislación & jurisprudencia , Defensa del Niño/legislación & jurisprudencia , Traumatismos Craneocerebrales/epidemiología , Predicción , Maltrato a los Niños/estadística & datos numéricos , Colorado/epidemiología , Femenino , Humanos , Lactante , Masculino , Morbilidad/tendencias , Estudios Retrospectivos , Tasa de Supervivencia/tendenciasRESUMEN
BACKGROUND AND OBJECTIVE: To reduce missed cases of pediatric abusive head trauma (AHT), Pediatric Brain Injury Research Network investigators derived a 4-variable AHT clinical prediction rule (CPR) with sensitivity of .96. Our objective was to validate the screening performance of this AHT CPR in a new, equivalent patient population. METHODS: We conducted a prospective, multicenter, observational, cross-sectional study. Applying the same inclusion criteria, definitional criteria for AHT, and methods used in the completed derivation study, Pediatric Brain Injury Research Network investigators captured complete clinical, historical, and radiologic data on 291 acutely head-injured children <3 years of age admitted to PICUs at 14 participating sites, sorted them into comparison groups of abusive and nonabusive head trauma, and measured the screening performance of the AHT CPR. RESULTS: In this new patient population, the 4-variable AHT CPR demonstrated sensitivity of .96, specificity of .46, positive predictive value of .55, negative predictive value of .93, positive likelihood ratio of 1.67, and negative likelihood ratio of 0.09. Secondary analysis revealed that the AHT CPR identified 98% of study patients who were ultimately diagnosed with AHT. CONCLUSIONS: Four readily available variables (acute respiratory compromise before admission; bruising of the torso, ears, or neck; bilateral or interhemispheric subdural hemorrhages or collections; and any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture) identify AHT with high sensitivity in young, acutely head-injured children admitted to the PICU.
Asunto(s)
Maltrato a los Niños/diagnóstico , Maltrato a los Niños/estadística & datos numéricos , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/epidemiología , Técnicas de Apoyo para la Decisión , Preescolar , Estudios Transversales , Femenino , Humanos , Lactante , Recién Nacido , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Masculino , Tamizaje Masivo/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Sensibilidad y Especificidad , Estados UnidosRESUMEN
OBJECTIVES: Our aim was to define the radiographic findings that help differentiate abusive head trauma (AHT) from accidental head injury. METHODS: Our trauma registry was queried for all children ≤5 years of age presenting with traumatic brain injury (TBI) from 1996-2011. RESULTS: Of 2,015 children with TBI, 71% had accidental injury and 29% had AHT. Children with AHT were more severely injured (ISS 22.1 vs 14.4; p < 0.0001) and had a higher mortality rate (15 vs 5%; p < 0.0001). Patients with AHT had higher rates of diffuse axonal injury (14 vs 8%; p < 0.0001) and subdural hemorrhage (76 vs 23%; p < 0.0001). Children with accidental injury had higher rates of skull fractures (52 vs 21%; p < 0.0001) and epidural hemorrhages (11 vs 3%). CONCLUSIONS: AHT occurred in 29% of children and resulted in increased mortality rates. These children had higher rates of subdural hemorrhages and diffuse axonal injury. Physicians initially evaluating injured children must maintain a high index of suspicion for abuse in those who present with subdural hematoma or diffuse axonal injury.
Asunto(s)
Accidentes/estadística & datos numéricos , Lesiones Encefálicas/diagnóstico por imagen , Lesiones Encefálicas/epidemiología , Maltrato a los Niños/estadística & datos numéricos , Tomografía Computarizada por Rayos X/métodos , Preescolar , Colorado/epidemiología , Diagnóstico Diferencial , Femenino , Humanos , Lactante , Masculino , Sistema de Registros/estadística & datos numéricosAsunto(s)
Abuso Sexual Infantil/prevención & control , Maltrato a los Niños/prevención & control , Protección a la Infancia/tendencias , Atención Primaria de Salud/tendencias , Niño , Predicción , Necesidades y Demandas de Servicios de Salud/tendencias , Humanos , Proyectos de Investigación , Estados UnidosRESUMEN
OBJECTIVE: Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma. METHODS: All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected. RESULTS: There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) (p=.003). CONCLUSION: In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.
Asunto(s)
Maltrato a los Niños , Composición Familiar , Fracturas Óseas/epidemiología , Adolescente , Adulto , Cuidadores , Niño , Preescolar , Colorado/epidemiología , Femenino , Fracturas Óseas/etiología , Humanos , Lactante , Masculino , Auditoría MédicaRESUMEN
BACKGROUND: Traumatic injuries are a major cause of morbidity and mortality in children. The purpose of the present study was to determine the incidence of nonaccidental trauma (NAT) and to compare the outcomes of accidental trauma (AT) patients with NAT patients at a large pediatric trauma center. METHODS: A retrospective chart review of 6186 trauma patients younger than 18 years evaluated during the period of 1996 to 2004. RESULTS: During the period of study, NAT accounted for 7.3% (n = 453) of trauma evaluations (n = 6186). Compared to AT, the NAT patient was younger, 12 vs 76 months (P < .05); were more severely injured, injury severity score 18 vs 9 (P < .05); and required both longer intensive care unit stay, 2 vs 1 day (P < .05), and overall hospital stay, 6 vs 3 days (P < .05). Craniotomy was required in 4.4% of NAT patients compared with 2.7 % of AT patients (P < .05). Abdominal exploration was necessary in 3.5% of NAT patients compared to 1.6% of AT patients. The mortality rate for NAT was 9.7% compared to 2.2% for AT (P < .05). CONCLUSIONS: The surgeon caring for children must appreciate the high incidence of NAT with its increased morbidity and mortality relative to AT patients. A surgical evaluation should be performed promptly in NAT patients because of their frequent need for emergent intervention.
Asunto(s)
Maltrato a los Niños/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Niño , Preescolar , Colorado , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Heridas y Lesiones/mortalidadRESUMEN
BACKGROUND: Nonaccidental trauma (NAT) causes significant morbidity and mortality in children. The purpose of this study was to characterize visceral injuries associated with NAT and the management and outcomes of children with these injuries. METHODS: During a 7-year period, children admitted to our regional pediatric trauma center with a diagnosis of NAT were identified and their injuries characterized. RESULTS: NAT accounted for 7% (n = 265 of 3705) of all trauma admissions during the period of study. Visceral injuries were diagnosed in 9% (n = 24 of 265) of NAT patients. Compared with the remaining NAT population, children with visceral injuries were similar in age and sex but had higher injury severity scores (21 vs. 17, P < .05). There was a high coincidence of thoracic trauma and nonburn integumental injuries in abdominally injured NAT patients. Children with visceral injuries were more likely to undergo emergent operations (46% [11 of 24] vs. 5% [15 of 241], P < .0001) than those without. However, there was no difference in Intensive Care Unit stay, hospital stay, or overall mortality for children with visceral injuries compared with those without. CONCLUSIONS: Visceral injuries are not uncommon in NAT, and these injuries often require emergent operative intervention. Thus, prompt evaluation and treatment by a surgeon remains a critical step in the management of children with NAT.
Asunto(s)
Traumatismos Abdominales/epidemiología , Vísceras/lesiones , Traumatismos Abdominales/diagnóstico , Adolescente , Niño , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/epidemiología , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Incidencia , Masculino , Traumatismo Múltiple/diagnóstico , Traumatismo Múltiple/epidemiología , Prevalencia , Estudios Retrospectivos , Tasa de Supervivencia , Traumatismos Torácicos/diagnóstico , Traumatismos Torácicos/epidemiología , Índices de Gravedad del Trauma , Estados Unidos/epidemiologíaAsunto(s)
Maltrato a los Niños/diagnóstico , Niño , Maltrato a los Niños/prevención & control , Maltrato a los Niños/estadística & datos numéricos , Preescolar , Humanos , Lactante , Notificación Obligatoria , Anamnesis , Examen Físico , Pronóstico , Factores de Riesgo , Estados Unidos/epidemiología , ViolenciaRESUMEN
This is a case describing an extensive esophageal perforation in a 15-day-old infant with an unclear mechanism of injury, who at 3 months of age presented as the victim of child abuse from a fatal closed head injury. Extensive esophageal perforation in a neonate or infant is usually induced by trauma, either accidental or non-accidental. When the given history does not correlate with the degree of injury, child abuse must be strongly suspected and a thorough social investigation must be undertaken.
Asunto(s)
Maltrato a los Niños/diagnóstico , Perforación del Esófago/etiología , Traumatismos Cerrados de la Cabeza/etiología , Síndrome del Bebé Sacudido/diagnóstico , Perforación del Esófago/diagnóstico , Resultado Fatal , Femenino , Traumatismos Cerrados de la Cabeza/diagnóstico , Humanos , Recién NacidoRESUMEN
BACKGROUND: Scientific and courtroom debate exists regarding the timing of onset of symptoms and the mechanism of injury in infants and children with inflicted traumatic brain injury (ITBI). OBJECTIVES: To determine the time interval between ITBI and the onset of symptoms and to explore the mechanism of ITBI. DESIGN, SETTING, AND PATIENTS: Retrospective review of all cases of pediatric ITBI admitted between January 1, 1981, and July 31, 2001, to a large academic medical center and cases admitted to 2 additional academic institutions between January 1, 1996, and August 31, 2000, and January 1, 2001, and July 31, 2001, comparing 81 cases of ITBI in which perpetrators admitted to abuse with 90 cases in which no abuse admission was made. The patients with perpetrator admissions to ITBI consisted of 53 boys (65%) and 28 girls (35%). Their ages ranged from 2 weeks to 52 months. MAIN OUTCOME MEASURES: Characteristics associated with perpetrator admissions to ITBI in children. RESULTS: Shaking was the most common mechanism of injury among all cases with perpetrator admissions: 55 (68%) of the 81 perpetrators admitted to shaking the children. Impact was not described in 44 (54%) of the 81 cases. In cases in which only impact was described, 60% (12/20) of the children showed skull or scalp injury, compared with 12% (4/32) with skull or scalp injury in the shake only group. In 52 (91%) of 57 cases in which the time to the onset of symptoms was described, symptoms appeared immediately after the abuse. In 5 cases (9%), the timing of symptoms was less clear, but they occurred within 24 hours. None of the children were described as behaving normally after the event. CONCLUSIONS: The symptoms of inflicted head injury in children are immediate. Most perpetrators admitted to shaking without impact. These data, combined with the relative lack of skull and scalp injury, suggest that shaking alone can produce the symptoms seen in children with ITBI.
Asunto(s)
Lesiones Encefálicas/diagnóstico , Maltrato a los Niños/estadística & datos numéricos , Lesiones Encefálicas/epidemiología , Lesiones Encefálicas/etiología , Preescolar , Femenino , Hematoma Subdural/epidemiología , Humanos , Lactante , Recién Nacido , Masculino , Síndrome del Bebé Sacudido/diagnóstico , Síndrome del Bebé Sacudido/epidemiología , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: Child fatality review teams have emerged across the United States in the past decade to address the concern that systems of child protection, law enforcement, criminal justice, and medicine do not adequately assess the circumstances surrounding child fatality as a result of maltreatment. METHODS: We compared data collected by a multidisciplinary child fatality review team with vital records for all children who were aged birth to 16 years and died in Colorado between January 1, 1990, and December 1, 1998. Odds ratios and 95% confidence intervals for ascertainment by the death certificate were estimated using logistic regression. RESULTS: Only half of the children who died as a result of maltreatment had death certificates that were coded consistently with maltreatment. Black race and female gender were associated with higher ascertainment, whereas death in a rural county was associated with lower ascertainment. Deaths resulting from violent causes (eg, shaking, blunt force trauma, striking) were more likely to be ascertained than those that involved acts of omission (eg, neglect and abandonment, drowning, fire). The most common perpetrators of maltreatment were parents. However, maltreatment by an unrelated perpetrator was 8.71 times (95% confidence interval: 3.52-21.55) more likely to be ascertained than maltreatment by a parent. CONCLUSIONS: The degree of underascertainment found in this study is of concern because most national estimates of child maltreatment fatality in the United States are derived from coding on death certificates. In addition, the patterns recognized in this study raise concern about systematic underascertainment that may affect children of specific sociodemographic groups.