The cause of infant and toddler subdural hemorrhage: a prospective study.

OBJECTIVE: To determine the frequency of child abuse and unintentional injury as a cause of infant and toddler subdural hemorrhage (SDH). METHODS: A prospective case series of a level I regional trauma center, regional children's hospital, and county medical examiner's office assessed consecutive children who were

Accusations that hospital staff have abused pediatric patients.

OBJECTIVE: Study objectives were to describe a hospital Child Protection Team's (CPT) efforts to develop and implement a protocol for systematic evaluation and management of accusations that hospital staff have abused pediatric patients, and to learn how to avoid problematic patient encounters and cope with existing accusations. METHOD: This study reports on a retrospective series of cases from one pediatric hospital between 1982 and 1996. It includes a survey of national children's hospitals' experience from 1990 through 1995. RESULTS: After initial complaints to our hospital's CPT, it became apparent that procedures were inadequate to protect the safety of patients and rights of the accused. A protocol for reporting, evaluation, and management of accusations was developed and implemented by the CPT. Thirty-four accusations of abuse of children by staff were reviewed. Seventeen of the physical abuse cases included bruising, fractures, rough handling, and verbal abuse. Eighteen sexual abuse complaints included touching and sexual statements. Complaints were substantiated in 23% of the accusations, and a third of the identified staff members were fired or resigned. Child victims had a high frequency of chronic illness. They and their families frequently had histories of prior abuse, mental illness, and social disarray. These factors made children more likely to become victims of real abuse and to misinterpret standard hospital procedures as abusive. All service areas of the hospital and types of hospital staff were accused of patient abuse. CONCLUSIONS: Few children's hospitals have formal protocols for internal management of or training programs to avoid complaints. Institutions and their staff who care for children should anticipate abuse complaints, train them in risk reduction methods, and develop accusation management plans.

Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network.

OBJECTIVES: To determine the frequency and location of bruises in normal infants and toddlers, and to determine the relationship of age and developmental stage to bruising. DESIGN: Cross-sectional survey. SETTING: Community primary care pediatric offices. SUBJECTS: Children younger than 36 months attending well-child care visits. METHODS: Prospective data collection of demographics, developmental stage, and presence and location of bruises. Any medical condition that causes bruises as well as known or suspected abuse was also recorded. A chi2 test or Fisher exact test was used to determine the significance of differences. MAIN OUTCOME MEASURES: Presence and location of bruises as related to age and developmental stage. RESULTS: Bruises were found in 203 (20.9%) of 973 children who had no known medical cause for bruising and in whom abuse was not suspected. Only 2 (0.6%) of 366 children who were younger than 6 months and 8 (1.7%) of 473 children younger than 9 months had any bruises. Bruises were noted in only 11 (2.2%) of 511 children who were not yet walking with support (cruising). However, 17.8% of cruisers and 51.9% of walkers had bruises (P<.001). Mean bruise frequency ranged from 1.3 bruises per injured child among precruisers (range, 1-2 bruises) to 2.4 per injured child among walkers (range, 1-11). The most frequent site of bruises was over the anterior tibia and knee. Bruises on the forehead and upper leg were common among walkers, but bruises on the face and trunk were rare, and bruises on the hands and buttocks were not observed at any age. There were no differences in bruise frequency by sex. African American children were observed to have bruises much less frequently than white children (P<.007). CONCLUSIONS: Bruises are rare in normal infants and precruisers and become common among cruisers and walkers. Bruises in infants younger than 9 months and who are not yet beginning to ambulate should lead to consideration of abuse or illness as causative. Bruises in toddlers that are located in atypical areas, such as the trunk, hands, or buttocks, should prompt similar concerns.

The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy.

PURPOSE: The aim of this study was to determine what percentage of childhood central venous catheters (CVC) are placed in victims of Munchausen syndrome by proxy (MSBP) and to evaluate the clinical indications and complications of CVCs in MSBP. METHODS: Study design was by retrospective chart review. Data were obtained from the regional children's hospital and regional child abuse consultation network. Patients in the MSBP series were all children who on consultation were determined to be victims of MSBP, from 1974 through 1996. Patients in the central catheter series were all children who had central venous catheters placed 1991 through 1995, excluding children whose catheters were placed for cancer chemotherapy or for chronic renal failure. Consultation records of MSBP cases were abstracted noting the clinical characteristics of victims and perpetrators. Hospital procedure codes were reviewed for children who had CVCs placed. Those who had discharge diagnostic codes that commonly require CVC placement were not reviewed, but charts of children with diagnoses not usually requiring CVCs were evaluated. Descriptive statistics and chi2 and Fisher's Exact test were used for comparisons. RESULTS: Sixteen of ninety-three (17%) of MSBP victims had central lines, including two deaths caused by assault through the lines. Line sepsis occurred in 9 of 16 (56%) patients. Primary reasons for CVC were for administration of medicines that can normally be administered orally or subcutaneously (7) or for severe nutritional depletion (8). All but one of the children had symptoms of multiple organ system involvement. Siblings had frequently been victimized. The mean age of symptom onset was 19 months, yet the mean age at diagnosis was delayed until 82 months. All perpetrators were the mother. Fathers were usually physically or emotionally unavailable. Nearly one third of mothers had prior medical training and one third had themselves been victims of prior physical or sexual abuse. Ten of fifteen mothers previously exhibited Munchausen behavior themselves. Of children at our institution who had central venous catheter placement, 8 of 709 (1.1%) were MSBP victims. CONCLUSIONS: CVCs are frequently placed in MSBP victims for physiological problems, malnutrition, or failure to respond to normal treatments. Surgeons should consider requesting systematic evaluation for MSBP in patients seeking CVC placement for diagnoses not usually requiring CVCs lest they become unintentional collaborators in abuse of these children.

Cervical spine MRI in abused infants.

OBJECTIVE: To determine clinical utility of screening with cervical spine MRI to detect unsuspected cord injury in children with head injury from child abuse. DESIGN: Prospectively collected case series. Setting-Tertiary care children's hospital and county medical examiner's office. PATIENTS: Twelve children with intracranial injury secondary to child abuse. None was clinically suspected to have cord injury. Includes all eligible children whose attending felt: (a) needed follow-up cranial imaging: (b) could be safely imaged; and (c) whose caretakers consented between November, 1991 and September, 1994. INTERVENTIONS: MRI scans of the cervical spine were obtained either more than 3 days after clinical presentation or postmortem. MAIN OUTCOME MEASURES: Clinical observations by neurologist, child protection team pediatrician and medicinal examiners by prospective protocol. MRI scans evaluated by prospective radiology protocol with emphasis on cervical cord injury. RESULTS: Four of the five autopsied children had small subdural or subarachnoid hemorrhages at the level of the cervical spine; MRI scan did not identify them. MRI did not identify cord injury in any child studied. CONCLUSION: Routine cervical spine MRI scans are probably not warranted in children with head injury secondary to child abuse without clinical symptoms of cervical cord injury.

Epidural hemorrhage: is it abuse?

OBJECTIVE: To determine whether children presenting with epidural hemorrhage (EDH) are as likely to have been abused as are children presenting with subdural hemorrhage (SDH). DESIGN: Retrospective chart review. SETTING: Level I regional trauma center and a regional children's hospital. PATIENTS: All children at both institutions 3 years old or younger with a diagnosis of EDH or SDH identified by a search of the computerized trauma registry and hospital medical records from 1985 through 1991. MEASUREMENT AND RESULTS: Complete records were found for 93 of 94 eligible subjects. The diagnosis of accidental or inflicted injury was ascertained from the patient's hospital medical record or the records of Child Protective Services. Of all subjects (n = 93), 52% (48/93) were male and the median age was 15 months. Abuse was diagnosed in 47% (28/59) of children with SDH and 6% (2/34) of those with EDH. Other significant injuries were found in 47% of children with SDH and 18% of children with EDH. There was no statistically significant difference between the two groups with respect to the likelihood of identifying a skull fracture, the need for surgical evacuation of the hemorrhage, or mortality. CONCLUSIONS: Our data are consistent with current biomechanical concepts of intracranial injury. EDHs results from brief linear contact forces that commonly occur in unintentional falls. SDHs are caused by global high-energy rotational acceleration/deceleration forces that are commonly generated in episodes of abuse. Compared with SDH, EDH rarely results from abuse.

Inflicted submersion in childhood.

OBJECTIVE: To improve characterization and recognition of inflicted pediatric submersions. DESIGN: Retrospective case series, records review. SETTING: A regional children's hospital and the King County (Washington) Medical Examiner's office. PATIENTS: Children younger than 19 years who sustained submersion injury between 1983 and 1991 and were hospitalized or autopsied. OUTCOME MEASURES: Two pediatricians, using preestablished criteria, categorized abstracted case scenarios as either inflicted or unintentional events. The two groups were compared. RESULTS: Of 205 submersions, 16 (8%) were judged to have been inflicted. Objective physical signs of abuse and incompatibilities between the history and the child's stage of development or physical findings were common (69% and 50%, respectively). Inflicted submersion victims were likely to be young (median age, 2.1 years). They tended to be the youngest sibling in a large (three or more children) household. Social and demographic attributes of inflicted and unintentional submersion victims did not differ significantly. Bathtubs were the most common site for inflicted submersions (9/16 [56%]), and submersions in bathtubs were frequently inflicted (9/34 [26%]). Compared with unintentional submersion victims, children who were inflicted submersion victims were less likely to be revived by bystanders (relative risk, 0.10; confidence interval, 0.01 to 0.72) and were more likely to die (relative risk, 4.32; confidence interval, 1.40 to 21.43). CONCLUSIONS: Enough childhood submersions are inflicted to warrant careful case evaluation. Bathtub submersion victims and children with physical and historical findings common to other forms of abuse are most likely to be the victims of inflicted submersion.

Inadequate history as a barrier to immunization.

OBJECTIVES: To evaluate how lack of immunization history contributes to missed opportunities for immunization and to document the effort required to obtain immunization history. DESIGN: Cross-sectional. SETTING: Urban, inner-city primary care pediatric clinic serving a low-income, multiethnic population. PATIENTS: Ninety-five new patients seen for either well-child care (53 patients) or acute illnesses (42 patients) during a 4-month period in 1993. Fifty-nine patients were aged 3 to 59 months and 36 were aged 5 to 15 years. MEASUREMENTS: Efforts to obtain immunization history were documented by means of a standardized data collection form. RESULTS: Immunization history was obtained for only 26 (27%) of 95 patients during the initial visit. Caregivers of 74 (78%) of 95 patients did not bring immunization records to the initial visit; they were no more likely to bring records for well-child care than for acute care or for younger vs older children. Parents brought immunization records more often than did nonparents. A total of 145 telephone calls were made and 30 letters were sent in an attempt to obtain immunization histories. Immunization records were never found for 10 new patients (11%). Thirty-two patients (34%) were found to be lacking immunizations. Of these, only three patients had contraindications to immunization at the initial visit. Therefore, in one third of our new patients, opportunities to immunize were missed solely because their immunization records were unavailable at the initial visit. In another one third of cases, caregivers had incorrectly believed their child's immunizations to be up to date. CONCLUSIONS: Opportunities to immunize children were often missed because of a lack of immunization history. Our experience supports the need for improved documentation of immunization histories.

Evolution of the cranial computed tomography scan in child abuse.

Computed tomography (CT) scans obtained at the time of clinical presentation have occasionally been reported to be normal in children with history and findings of significant abusive head injury. We have retrospectively observed abnormalities in "normal" scans of some similar children. We have also seen abnormalities develop on serial scanning. To determine how frequently these situations occur, we reviewed charts of 34 children with a final diagnosis of child abuse who also had cranial CT scans performed. Their CT scans were retrospectively reviewed by a pediatric radiologist. Eleven (11/34) CT scans had initially been interpreted as normal. Four (4/11) of these had been reinterpreted during the hospitalization as abnormal, affecting medical (1) and legal (3) outcome. Repeat scanning in three of the remaining seven resulted in surgical drainage of a subdural effusion (1) and affected legal outcome (2). Four of the seven initial scans felt normal throughout the hospitalizations were judged abnormal on retrospective review. This evaluation was confirmed in the two rescanned. Initial CT interpretation most often failed to appreciate changes in parenchymal density and small amounts of falcine or cortical subdural blood. Subsequent scans also showed evolving effusions and infarcts. Changes were noted in 1 1/2 to 5 days. The CT scan frequently shows subtle changes in the immediate posttrauma period. If the child does not recover promptly, subsequent scans frequently result in significant changes in clinical and legal management.

When is childhood drowning neglect?

Concern that drowning is frequently considered neglectful and referred to Children's Protective Services (CPS) led us to review the frequency and associations of referral. Records of 95 childhood drowning and near drowning victims hospitalized between 1981 and 1987 were reviewed. Reactions of 14 nurses, 27 physicians, and 13 social workers to 4 case scenarios were solicited. Only 8 drownings were reported to CPS. Reporting was significantly more likely if the child was younger or nonwhite, the family poor, the injury in the bathtub, social work involved, a prior CPS report recognized or consideration of neglect documented in the chart. Reporting was not related to the child's sex or clinical outcome, the parent's marital status or drug/alcohol history, type of child supervision, or time until discovery or history of prior accidents. Only 28% of the cases had social service evaluation. Intensive care staff were least likely and emergency room staff most likely to consider drowning scenarios neglectful. Profession, age, sex, years in practice and whether one was a parent did not affect the referral decision. Judgment that scenarios were neglectful correlated closely with the decision to report. Lapse in supervision by an intoxicated father, was thought most neglectful. Judgment was split whether poor families letting infants bathe alone or with siblings were neglectful or the result of poor knowledge of hazard and infant development. A 4-year-old who wandered into a lake at a picnic was felt a victim of an unfortunate accident. Clinicians found decisions about referral stressful.(ABSTRACT TRUNCATED AT 250 WORDS)

Positional asphyxia in individuals with severe cerebral palsy.

The authors report the accidental death by positional asphyxia of three individuals with cerebral palsy occurring after they had been placed in bed for the night. During the five-year period between 1984 and 1989, 12 per cent of deaths from positional asphyxia in King County, Washington, involved individuals with cerebral palsy. Such accidents are similar to those occurring among healthy young children, perhaps because both groups have limited motor skills. Further research into accidents among disabled persons may clarify their special risks and possibly lead to modifications in bed design.

Tap water burn prevention: the effect of legislation.

Five years after a 1983 Washington State law required new water heaters to be preset at 49 degrees C (120 degrees F), 77% of homes (84% of homes with postlaw and 70% of homes with prelaw water heaters) had tap water temperatures of less than 54 degrees C. In 1977, 80% of homes had tap water temperatures greater than 54 degrees C. Mean temperature in 1988 was 50 degrees C compared with 61 degrees C in 1977. Both changes were significant compared with 1977 temperatures. Few people increased their heater temperature after installation. Eighteen burn victims were identified from July 1979 through May 1988, for an average admission rate of 2.4 per year, compared with 5.5 per year in the 1970s. Compared with the 1970s, total body surface area burned, mortality, grafting, scarring, and length of hospital stay were all reduced, while the likelihood that scald burns were the result of child abuse increased to 50%. Both education campaigns and legislation have resulted in significantly safer water temperatures. Further, this change seems to have resulted in a reduction in frequency, morbidity, and mortality of tap water burn injuries in children. Lower water heater settings proved acceptable to the consumer.

Nutritional rickets.

Nutritional rickets was diagnosed in 18 infants aged eight to 24 months. Clinical features included progressive leg bowing, poor linear growth, a diet deficient in vitamin D, seizures, and abnormal serum calcium, phosphate and alkaline phosphatase levels. Wrist radiographs and serum alkaline phosphatase levels were the most useful confirmatory tests. Breast milk may not contain enough vitamin D to protect infants, particularly dark-skinned children and those living in cloudy, northern U.S. cities, from rickets after six months of age. As breast feeding becomes more widely practiced, care is required to ensure that infants at high risk for rickets receive appropriate vitamin D supplementation.

Psychologic morbidity of children subjected to Munchausen syndrome by proxy.

Munchausen syndrome by proxy is being recognized and reported with increasing frequency, which suggests that it is more common and occurs with a wider spectrum of severity than was previously suspected. In past reports, the difficulties of detecting and documenting the syndrome have been emphasized, as well as its physical morbidity and mortality. The psychologic morbidity of Munchausen syndrome by proxy in six children is described. The children reacted with developmentally appropriate behavior problems ranging from feeding disorders in infants, withdrawal and hyperactivity in preschool-aged children, to hysterical disorders and personal adoption of Munchausen syndrome behavior in adolescents. Parental psychologic and behavioral styles, family dynamics, and responses from legal and children's protective services systems make protection of the child within the home difficult, if not impossible. Even with protection from further physical injury, severe psychologic trauma remains likely. Extreme caution is suggested in allowing these children to remain in the family.