Screening injured children for physical abuse or neglect in emergency departments: a systematic review.

BACKGROUND: Screening markers are used in emergency departments (EDs) to identify children who should be assessed for possible physical abuse and neglect. We conducted three systematic reviews evaluating age, repeat attendance and injury type as markers for physical abuse or neglect in injured children attending EDs. METHODS: We included studies comparing markers in physically abused or neglected children and non-abused injured children attending ED or hospital. We calculated likelihood ratios (LRs) for age group, repeat attendance and injury type (head injury, bruises, fractures, burns or other). Given the low prevalence of abuse or neglect, we considered that an LR of 10 or more would be clinically useful. RESULTS: All studies were poor quality. Infancy increased the risk of physical abuse or neglect in severely injured or admitted children (LRs 7.7-13.0, 2 studies) but was not strongly associated in children attending the ED (LR 1.5, 95% CI: 0.9, 2.8; one study). Repeat attendance did not substantially increase the risk of abuse or neglect and may be confounded by chronic disease and socio-economic status (LRs 0.8-3.9, 3 studies). One study showed no evidence that the type of injury substantially increased the risk of physical abuse or neglect in severely injured children. CONCLUSIONS: There was no evidence that any of the markers (infancy, type of injury, repeated attendance) were sufficiently accurate (i.e. LR >or= 10) to screen injured children in the ED to identify those requiring paediatric assessment for possible physical abuse or neglect. Clinicians should be aware that among injured children at ED a high proportion of abused children will present without these characteristics and a high proportion of non-abused children will present with them. Information about age, injury type and repeat attendances should be interpreted in this context.

Performance of screening tests for child physical abuse in accident and emergency departments.

OBJECTIVES: To determine the clinical effectiveness of screening tests for physical abuse in children attending accident and emergency (A&E) departments in the UK. DATA SOURCES: Searches were limited to studies published after 1974 and were carried out from August 2004 to October 2006 using the following methods: searching electronic databases, searching the publications catalogue of the NSPCC, scanning reference lists, hand-searching journals, searching the internet, approaching professional contacts for unpublished data, and searching in three key journals. REVIEW METHODS: A simple decision-analytic model was used to integrate the findings of nine systematic reviews regarding the incidence of physical abuse, the characteristics of children attending A&E, and the performance of screening tests for physical abuse. RESULTS: A total of 66 studies, including 11 unpublished studies, were included in the nine systematic reviews. Overall the quality was poor. There was consistent evidence that physical abuse affects about 1 in 11 children in the UK each year. The proportion of abused children requiring medical attention is small but poorly quantified. Approximately 1% of all attendances of injured children at A&E are for physical abuse. There was clear evidence that physically abused children attending A&E are missed, but the performance of the clinical screening assessment was poorly quantified. There was no evidence that any test was highly predictive of physical abuse. Among severely injured children admitted to hospital, those under 1 year were more likely to be abused than older children. However, evidence that young age was a risk factor for abuse among all injured children attending A&E was inconsistent. There was weak evidence that a community liaison nurse improved the performance of the screening assessment in A&E, and it was estimated that combining a nurse with the standard screen would result in referral to social services of about half of the abused children attending A&E. However, given the poor quality of the data, this is highly uncertain. The addition of screening protocols to the clinical screening assessment offered marginal benefits, and additional false-positive referrals exceeded additional abused children detected. The benefits of protocols declined as the accuracy of the clinical screening assessment improved. The most effective protocol was to refer all injured infants and children who were social work active. CONCLUSIONS: Improving clinical screening assessment is likely to be more useful than protocols in improving the detection of physically abused children attending A&E. Further improvements might be achieved by following up children referred to paediatricians for suspected abuse who fail to reach the high level of certainty required to justify referral to social services. Many professionals voiced a need for access to experienced social services advice that is not under pressure to minimise referrals to an overloaded service, and consideration might be given to making such advice centrally available.

Factors associated with the initiation of alpha-interferon treatment in Medicaid patients diagnosed with hepatitis C.

We aimed to determine rates of treatment with alpha-interferon medication in patients diagnosed with hepatitis C virus (HCV), to ascertain the prevalence of selected conditions that could influence initiation of interferon treatment, and to examine the association between the presence of these conditions and interferon treatment. A nested case-control design was used in California Medicaid (Medi-Cal) claims data covering the period from 1 January 1996 to 30 June 2002. Interferon-treated cases and non-treated controls were selected in a 1 : 2 ratio that matched the length of the observation period and year of index HCV diagnosis. Predictor variables examined in bivariate and multivariate analyses included demographics, substance abuse and dependence, psychotropic drug use, selected chronic conditions and medical utilization. The proportion of eligible subjects diagnosed with HCV and treated with interferon ranged from 10.7 to 13.9%. There were 529 treated cases that met the eligibility criteria and 1058 non-treated HCV patients selected as controls. Multivariate factors that increased the likelihood of treatment were a liver biopsy, a diagnosis of mild liver disease, a diagnosis of psoriasis, antidepressant use and classification of race/ethnicity as 'other'. A decreased likelihood of treatment was linked to age > or =65 years, a diagnosis of kidney disease, one to four emergency visits and five or more emergency visits. The proportion of patients receiving interferon treatment in the Medi-Cal-insured population was low compared with published rates in HCV patients in other general medical settings. The diverse factors linked to initiation of HCV therapy raise compelling questions for further research.

Overcoming barriers to hepatitis B immunisation by a dedicated hepatitis B immunisation service.

AIMS: To determine the effectiveness of a selective hospital based hepatitis B immunisation programme and the barriers to be overcome in obtaining a successful outcome. METHODS: Retrospective case note review of 265 infants born over a five year period to hepatitis B carrier mothers at a university affiliated hospital in Hackney, London. RESULTS: A total of 242 infants (91%) were fully vaccinated; 217 (82%) had serology; 31 required booster doses. Percentages failing to reach second, third vaccinations, and serology on schedule rose exponentially (7%, 18%, 33% respectively). Mobility was high (25%) and significantly affected outcome. A total of 95% Hackney resident babies were fully vaccinated compared with 78% non-residents. Uptake of routine immunisations was higher in Hackney residents than non-residents and greater in those who were eligible for hepatitis B vaccine. Name changes occurred in 35%. Translation requirements were high (85% for Turkish, Vietnamese, and Asian families). Requirements for specific postnatal counselling of mothers and hepatology referral fell significantly during the course of the study. Only seven of 22 babies born in 1995 in Tower Hamlets compared with 53 of 58 Hackney babies received a full vaccination course in non-hospital based primary care. CONCLUSION: In inner city areas with high prevalence of hepatitis B carriage, mobility, and diverse ethnicity, a dedicated centralised immunisation service can be highly effective, provided that adequate support services (translation, counselling, and parental referral) are available.

West African children in private foster care in City and Hackney.

A unique feature of some Africans who come to study and work in Britain is the practice of making private arrangements to send their children to live with foster parents who assume full parental rights. Six hundred randomly selected African families, with a child born between June 1988 and May 1991, resident in one Health Authority, were sent a questionnaire to elicit the proportion of children who had been in private foster care and to gain information on the knowledge and attitudes to fostering and day care provision. Families with children in foster care were asked additional questions about their experiences. Two hundred and six (34%) of the questionnaires were analysed. Seventy-six per cent of the respondents were from Nigeria, 65% had already heard about private fostering and 29 (14%) had sent one of their children to private foster care. Only one family felt that foster care was a suitable option; the reminder would have preferred alternative facilities such as nursery placement. Of the 29 children in foster care, nine parents said their children were unhappy and five rated the foster parents as bad. Contrary to popular belief, most children were visited fortnightly, some more frequently and only two never visited. Private fostering in this group of children was found to be less common than in earlier studies.

Cytomegalovirus infection and HIV-1 disease progression in infants born to HIV-1-infected women. Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection Study Group.

BACKGROUND AND METHODS: Cytomegalovirus (CMV) has been implicated as a cofactor in the progression of human immunodeficiency virus type 1 (HIV-1) disease. We assessed 440 infants (75 of whom were HIV-1-infected and 365 of whom were not) who had known CMV status and were born to HIV-1-infected women and who were followed prospectively. HIV-1 disease progression was defined as the presence of class C symptoms (according to the criteria of the Centers for Disease Control and Prevention [CDC]) or CD4 counts of less than 750 cells per cubic millimeter by 1 year of age and less than 500 cells per cubic millimeter by 18 months of age. RESULTS: At birth the frequency of CMV infection was similar in the HIV-1-infected and HIV-1-uninfected infants (4.3 percent and 4.5 percent, respectively), but the HIV-1-infected infants had a higher rate of CMV infection at six months of age (39.9 percent vs. 15.3 percent, P=0.001) and continued to have a higher rate of CMV infection through four years of age (P=0.04). By 18 months of age, the infants with both infections had higher rates of HIV-1 disease progression (70.0 percent vs. 30.4 percent, P=0.001), CDC class C symptoms or death (52.5 percent vs. 21.7 percent, P=0.008), and impaired brain growth or progressive motor deficits (35.6 percent vs. 8.7 percent, P=0.005) than infants infected only with HIV-1. In a Cox regression analysis, CMV infection was associated with an increased risk of HIV-1 disease progression (relative risk, 2.59; 95 percent confidence interval, 1.13 to 5.95). Among children infected with HIV-1 alone, but not among those infected with both viruses, children with rapid progression of HIV-1 disease had higher mean levels of HIV-1 RNA than those with slower or no progression of disease. CONCLUSIONS: HIV-1-infected infants who acquire CMV infection in the first 18 months of life have a significantly higher rate of disease progression and central nervous system disease than those infected with HIV-1 alone.

Paediatric community vision screening--a new model.

The purpose of this study was to establish if a community based model using a Hospital Optometrist and Community Orthoptist can provide a practical secondary vision screening service for children. These professionals working in an Inner London Health Centre, assessed children who had failed primary vision screening. In total 483 new patients were seen between April 1994 and March 1996 with the largest referral source being the school nurse screening programme. The majority were managed by the team with a total onward referral rate to the Hospital Eye Service of 14%. In 78% of these cases the consultant's diagnosis agreed with the reason for referral. Where the consultant's diagnosis differed the children were identified as normal or a variant of normal. This model of care provides a 'one stop service' where a child identified as having a potential visual problem at primary screening can be assessed, refracted and provided with spectacles in a local setting without hospital referral. Referrals to the Hospital Eye Service are considerably reduced and a convenient service is provided for parents and children.

Maternal and perinatal factors related to maternal-infant transmission of HIV-1 in the P2C2 HIV study: the role of EBV shedding. Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV-1 Infection (P2C2 HIV) Study Group.

The association of maternal and perinatal factors with mother-infant transmission of HIV-1 was examined in a prospective multicenter cohort of singleton live births to 508 HIV-1-infected women with children of known HIV-1 infection status (91 [18%] HIV-1-infected, 417 [82%] uninfected). From multivariate logistic regression, independent predictors of HIV-1 transmission included maternal CD4 percentage (CD4%) (odds ratio [OR] per 10% increase in CD4% = 0.70; p = .003), ruptured membranes <24 hours (OR = 3.15; p = .02), and maternal bleeding (OR = 2.90; p = .03), whereas maternal zidovudine (ZDV) use was marginally associated (OR = 0.60; p = .08). The associations of maternal urinary cytomegalovirus (CMV) shedding, oropharyngeal Epstein-Barr virus (EBV) shedding, and serology profiles during pregnancy with HIV-1 transmission were examined in the subset of mothers in whom the CMV and EBV measurements were available. Maternal EBV seropositivity, CMV shedding, and CMV seropositivity were 100% (279 of 279), 7% (16 of 229), and 92% (270 of 274), respectively. These rates did not differ between transmitting and nontransmitting mothers. In univariate analyses, maternal EBV shedding was higher among transmitting than nontransmitting mothers (40 of 49 [82%] compared with 154 of 226 [68%]; p = .06) and was independently associated with transmission in multivariate logistic analyses adjusting for CD4%, ruptured membranes, and ZDV use, with an OR of 2.45 (95% confidence interval (CI), 1.03-5.84; p = .04). This permits the conclusion that EBV shedding is associated with maternal-infant HIV-1 transmission, independent of CD4%.

HIV vertical transmission rate determinations are subject to differing definitions and therefore different rates. The Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection Study Group.

The HIV infection status of a cohort of 600 prospectively followed children born to HIV infected mothers was determined using HIV peripheral blood culture tests at 0, 3, and 6 months of age, HIV serology at > or = 15 months, and CDC AIDS criteria. We estimated transmission rates using five methods which differed in how HIV indeterminates are handled. These methods were applied at two points in time to illustrate effects of length of follow-up of the cohort on results. In January 1997, 30 months after the last birth, transmission rate estimates ranged from 15.5% (known positives/known positives x known negatives) to 18.1% (known positives x those with one positive culture x deaths/entire cohort minus those lacking negative cultures at age > or = 5 months). Estimates ranged from 14.8% to 20.7% using the subcohort of 284 children followed > or = 12 months as of May 1993. These results indicate that methods for assigning HIV infection status and for handling HIV indeterminates should be carefully defined when estimating transmission rates.

Growth failure as the first expression of malnutrition in children with human immunodeficiency virus infection.

BACKGROUND: To define the onset, pattern, and earliest manifestations of malnutrition related to HIV infection. METHODS: A retrospective cross-sectional analysis of changes in weight and growth in a group of 54 children with perinatally acquired HIV infection was conducted. Eight children had asymptomatic HIV infection, 26 had symptomatic infection, and 20 had symptomatic infection and were referred for nutritional support. RESULTS: We found an early decline in the rate of linear growth with a relative preservation of the weight-for-age. Weight-for-height measurements were preserved until there was advanced HIV-related disease. CONCLUSIONS: This pattern can result in a false impression of adequate nutrition and emphasizes the importance of longitudinal growth data of the child with HIV infection. Evidence of linear growth failure before clinical wasting is apparent is an absolute indication for aggressive nutritional support.

Varicella-zoster virus infection in children with underlying human immunodeficiency virus infection.

This article describes a prospective longitudinal study of varicella-zoster virus (VZV) infections in human immunodeficiency virus (HIV)-infected children, designed to determine their natural history of VZV infection and possible effects of VZV on the progression of HIV infection. Varicella was usually not a serious acute problem, and it did not seem to precede clinical deterioration. The rate of zoster was high: 70% in children with low levels of CD4+ lymphocytes at the time of development of varicella. It is predicted that immunization with live attenuated varicella vaccine is unlikely to be deleterious to HIV-infected children. Moreover, if they are immunized when they still have relatively normal levels of CD4+ lymphocytes, they may have a lower rate of reactivation of VZV than if they were allowed to develop natural varicella when their CD4+ cell counts have fallen to low levels as a result of progressive HIV infection.