Medical Neglect in Childhood.

This introduction provides an overview to the special issues on medical neglect in childhood guest edited by Barbara L. Knox, MD, FAAP, Clinical Professor of Pediatrics, University of Washington School of Medicine, The Children's Hospital at Providence, Medical Director of Alaska Child Abuse Response and Evaluation Services; Randell C. Alexander, MD, PhD, FAAP, Professor and Chief, Division of Child Protection and Forensic Pediatrics at the University of Florida-Jacksonville; Francois M. Luyet, MD, Clinical Assistant Professor, University of Wisconsin School of Medicine and Public Health; and Debra D. Esernio-Jenssen, Professor of Pediatrics at the Morsani College of Medicine USF Health in Tampa, Florida and the Chief of Child Protection Medicine at Lehigh Valley Reilly Children's Hospital. Ten articles are included in this special edition aiming to explore the role of medical neglect in situations commonly encountered by practitioners.

Malnutrition and Medical Neglect.

Anomalies found during the assessment of nutrition in children are common in pediatric practice, yet few articles address the intersection between malnutrition and medical neglect. The diagnosis of medical neglect requires several components including a) harm, or risk of harm due to lack of recommended health care, b) recommended care provides benefit significantly greater than potential risk, c) caregiver understands the medical recommendations; and d) has access to the recommended care, but fails to utilize it. Through the application of this definition to cases of malnutrition, considerations for diagnosing medical neglect when presented with malnutrition are reviewed. Cases include children with special healthcare needs, children exposed to selective diets, previously well children with severe malnutrition, and treatment-resistant failure to thrive. Obesity is a state of malnutrition, which may also involve neglect; in this instance, the "neglect" involves failure to supervise nutritional intake necessary for optimal functioning. Because many cases involve interactions with medical providers, the subsequent failure to follow medical advice regarding obesity management may also be considered medical neglect. This article reviews the relationship between medical neglect, nutritional deprivation, and over-nutrition to explore when a diagnosis of medical neglect may be applicable.

The "New Science" of Abusive Head Trauma.

Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.

Association of Friday School Report Card Release With Saturday Incidence Rates of Agency-Verified Physical Child Abuse.

Importance: Corporal punishment is a leading risk factor for physical abuse. Strong anecdotal evidence from physicians and other professionals working in child protection suggest that punishment-initiated physical abuse for school-aged children increases after release of report cards. However, no empirical examination of this association has occurred. Objective: To examine the temporal association between school report card release and incidence rates (IRs) of physical abuse. Design, Setting, and Participants: This retrospective study reviewed calls to a state child abuse hotline and school report card release dates across a single academic year in Florida. Data were collected in a 265-day window from September 8, 2015, to May 30, 2016, in the 64 of 67 Florida counties with report card release dates available (16 960 days). Participants included all children aged 5 to 11 years for whom calls were made. A total of 1943 verified cases of physical abuse were reported in the study period in the 64 counties. Data were analyzed from October 2017 through May 2018. Exposures: School report cards release across a single academic year, measured daily by county. Main Outcomes and Measures: Daily counts of calls to a child abuse hotline that later resulted in agency-verified incidents of child physical abuse across a single academic year by county. Results: During the academic year, 167 906 calls came in to the child abuse hotline for children aged 5 to 11 years; 17.8% (n = 29 887) of these calls were suspected incidents of physical abuse, and 2017 (6.7%) of these suspected incidents were later verified as cases of physical abuse before excluding the 3 counties with no release dates available. Among the 1943 cases included in the analysis (58.9% males [n = 1145]; mean [SD] age, 7.69 [1.92] years), calls resulting in verified reports of child physical abuse occurred at a higher rate on Saturdays after a Friday report card release compared with Saturdays that do not follow a Friday report card release (IR ratio, 3.75; 95% CI, 1.21-11.63; P = .02). No significant association of report card release with IRs was found for any other days of the week. Conclusion and Relevance: This association of school report card release and physical abuse appears to illustrate a unique systems-based opportunity for prevention.

Medical Evaluations Then and Now.

The role of medicine for children suspected of having been sexually abused has advanced significantly since the 1980s. Newer tests such as DNA and nucleic acid amplification have added to the detection of perpetrators and disease, respectively. Non-acute examination physical findings are seen in only 5% to 10% of instances. Physical findings regarding the hymen and anus have been found to often be normal variants-findings that some used to regard as signs of sexual abuse. Newer considerations for clinicians include Internet child pornography, human trafficking, and use of video/photographic recording. New technologies such as high definition digital photography and telemedicine help to document abuse in a much improved way than existed several decades ago. Nevertheless, the basic approach of careful history-taking remains a bedrock for the diagnosis of child sexual abuse.

Introduction to the special section: medical advances in child sexual abuse, part 2.

This volume is the second of a two-part special issue detailing state of the art practice in medical issues around child sexual abuse. The four articles in this special section discuss topics such as estimating the sexual maturity of a child from computer or photographic images; how several cases of supposed Neisseria gonorrhoeae meningitis actually were a different, but related, organism, thereby removing sexual abuse as a consideration as to etiology; what current laboratory methods are available today to detect specific sexually transmitted infections and what should be used; and how all the evidence in child sexual abuse cases is organized to make clear and accurate statements.

Neisseria-avoiding the jump to conclusions.

Neisseria gonorrhoeae infection in a prepubertal child is virtually diagnostic of sexual abuse, provided perinatal infection has been excluded. Therefore, it is imperative that Neisseria gonorrhoeae be correctly identified. We present two cases of false positive Neisseria gonorrhoeae meningitis encountered at two different children's hospitals. Both cases were evaluated by the child protection teams prior to establishing the correct diagnosis.

Medical advances in child sexual abuse.

This volume is the first of a two-part special issue detailing state of the art practice in medical issues around child sexual abuse. The six articles in this issue explore methods for medical history evaluation, the rationale for when sexual examinations should take place, specific hymenal findings that suggest a child has been sexually abused, the healing of genital injuries, approaches to interpretation of medical findings, and the neurological harm of sexual abuse. From the initial history to the process of the medical examination, the mechanics of what a genital examination might show, and the neurobiological consequences, it is demonstrated that the harm of sexual abuse is has more effect on the brain than the genital area.

Conducting the medical history.

A key portion of the medical evaluation of child sexual abuse is the medical history. This differs from interviews or histories obtained by other professionals in that it is focuses more on the health and well-being of the child. Careful questions should be asked about all aspects of the child's medical history by a skilled, compassionate, nonjudgmental, and objective clinician. Often the diagnosis of sexual abuse is based only on the medical history. The history can be further understood by knowledge of how children are abused and their reactions to it. By addressing the child's and parent's concerns, reassurance can also be provided about what is normal and abnormal with the child's body.

Child fatality review teams.

The history of child fatality review (CFR) begins with the work of Ambrose Tardieu in 1860. More than a century later, in 1978, the first team was established in Los Angeles, California. This article reviews the history of CFR, the composition of teams, and its purpose based in preventive public health. The successes of three decades and challenges for the future of CFR are discussed.

Shaken baby syndrome and a baby's cry.

The aim of this study was to investigate the relationship between crying of an infant and inflicted head injury by shaking and/or impact. During the period between January 1, 1997 and December 31, 2003, 26 cases of shaken baby syndrome (SBS) were identified in Estonia. The incidence of SBS was 28.7 per 100,000 children under 1 year of age during the whole study period. In this group there were four children from twin pairs: two twin boys and a girl from a twin pair and a boy from another twin pair. This represents 15.4% of the 26 cases. Twins in Estonia represent 2.12% of infant births. The mean age on admission was 3.9 months. According to outpatient records almost all parents (88.5%) in the study group (23/26) had contacted their family physicians and other specialists because of excessive crying or irritability of the baby prior to the admission to the hospital with SBS or death. We found that the time curve of crying was similar to the curve of highest incidence of cases of SBS except the crying curve began earlier. CONCLUSION. Our data confirm that the families with twins are at additional risk for SBS and parent's complaints of excessive crying of their infants should be taken as signal that parents need to be carefully counselled.

Guidelines for postmortem protocol for ocular investigation of sudden unexplained infant death and suspected physical child abuse.

Postmortem examination is a cornerstone in identifying the cause of unexplained sudden death in children. Even in cases of suspected or known abuse, an autopsy may help characterize the nature of the abuse, which is particularly important in the forensic autopsy of children in the first 3 to 4 years of life when inflicted neurotrauma is most common. Forensic examinations are vital in cases that might otherwise be diagnosed as sudden infant death syndrome. The ocular autopsy in particular may demonstrate findings that were not appreciated on antemortem clinical examination. This protocol for postmortem examination of the eyes and orbits was developed to promote more consistent documentation of findings, improved clinical and forensic decision making, and more replicable and coherent research outcomes.

Western medicine and traditional healers: partners in the fight against HIV/AIDS.

Prevention and control programs for HIV/AIDS have had limited success, especially in sub-Saharan Africa. Not surprising, most residents see traditional healers as their only option to meet their healthcare needs. Some patients refuse surgery or other medical treatment unless their traditional healer sanctions the treatment first. Formally trained doctors have finally begun to consider traditional healers as potential allies in the battle to prevent the spread of HIV/AIDS by recognizing that the longstanding trust and credibility of these healers in the black communities can facilitate change in sexual behavior. Innovative and effective approaches, including utilization of traditional healers, can play a vital role in Africa's AIDS prevention and control programs.

Media influences on children and adolescents: violence and sex.

The portrayal of violence, sex, and drugs/alcohol in the media has been known to adversely affect the behavior of children and adolescents. There is a strong association between perceptions of media messages and observed behavior, especially with children. Lately, there has been more of a focus in the public health/medical field on media influences of youth and the role of the pediatrician and/or healthcare worker in addressing this area of growing concern. There is a need to explicitly explore the influences of media violence, sex, and drugs/alcohol on youth within the context of the Social Learning Theory. Implications of these influences are discussed, and recommendations for pediatricians and/or health care workers who interact with children and adolescents are described. Pediatricians and health care workers should incorporate media exposure probes into the developmental history of their patients and become knowledgeable about the effects of medial influences on youth.