Identifying inflicted injuries in infants and young children.

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Validity evidence for a novel multiple-choice question bank in the field of child abuse pediatrics.

BACKGROUND: Though child abuse pediatrics has been a board-certified subspecialty for 15 years, there are few formalized board preparation resources available. OBJECTIVE: The purpose of this project was to establish a multiple-choice question bank with sufficient validity evidence for use in preparation for the child abuse pediatrics board examination. PARTICIPANTS AND SETTING: The question bank was distributed via an electronic child abuse pediatrics mailing list. Participants completing the entire question bank included 27 board-certified child abuse pediatricians (CAPs), 19 board-eligible CAPs, and 18 CAP fellows. METHODS: We used Messick's framework to conduct the validity investigation, which includes five components: content evidence, response process, internal structure, relation to other variables, and consequences. Item analyses included difficulty index, discrimination index, and distractor analysis. We used Cronbach's alpha to estimate internal consistency reliability. We conducted linear regressions of scores on the question bank compared to in-training exam scores and career stage. RESULTS: Eighty-four participants completed part of the question bank, and 64 completed the entire question bank. Of the original 117 questions ("items"), 94 met inclusion criteria. The mean score among board-certified CAPs was 80 %, and among participants reporting passing third-year ITE scores was 81 %. Correlation coefficient of scores on this question bank by career stage was r = 0.94, and by year of fellowship was r = 0.99. Cronbach's alpha for internal consistency reliability was 0.83. CONCLUSIONS: This multiple-choice question bank is the first question bank with a robust validity investigation for use by child abuse pediatrics trainees.

Subdural hemorrhage, macrocephaly, rash, and developmental delay in an infant: A pathogenic variant in NLRP3 causes CINCA/NOMID.

Subdural hemorrhages (SDHs) in children are most often observed in abusive head trauma (AHT), a distinct form of traumatic brain injury, but they may occur in other conditions as well, typically with clear signs and symptoms of an alternative diagnosis. We present a case of an infant whose SDH initially raised the question of AHT, but multidisciplinary evaluation identified multiple abnormalities, including rash, macrocephaly, growth failure, and elevated inflammatory markers, which were all atypical for trauma. These, along with significant cerebral atrophy, ventriculomegaly, and an absence of other injuries, raised concerns for a genetic disorder, prompting genetic consultation. Clinical trio exome sequencing identified a de novo likely pathogenic variant in NLRP3, which is associated with chronic infantile neurological, cutaneous, and articular (CINCA) syndrome, also known as neonatal-onset multisystem inflammatory disease (NOMID). He was successfully treated with interleukin-1 blockade, highlighting the importance of prompt treatment in CINCA/NOMID patients. This case also illustrates how atraumatic cases of SDH can be readily distinguished from AHT with multidisciplinary collaboration and careful consideration of the clinical history and exam findings.

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.

"Help Me Sleep": A Quality Initiative to Reduce Overnight Vital Signs.

BACKGROUND AND OBJECTIVES: Sleep is an essential part of the recovery process, yet inpatient sleep quality is poor. Patients and families report that vital signs are the most bothersome overnight disruption. Obtaining vital signs every 4 hours (Q4H) is not evidence-based and is frequently ordered indiscriminately. We aimed to decrease the percentage of patient nights with vital sign checks between 12 am and 6 am in a low-risk population from 98% to 70% within 12 months to minimize overnight sleep disruptions and improve inpatient sleep. METHODS: We conducted a quality improvement project on 3 pediatric hospital medicine teams at a large free-standing children's hospital. Our multidisciplinary team defined low-risk patients as those admitted for hyperbilirubinemia and failure to thrive. Interventions were focused around education, electronic health record decision support, and patient safety. The outcome measure was the percentage of patient nights without a vital sign measurement between 12 am and 6 am and was analyzed by using statistical process control charts. Our process measure was the use of an appropriate vital sign order. Balancing measures included adverse patient events, specifically code blues outside the ICU and emergent transfers. RESULTS: From March 2020 to April 2021, our pediatric hospital medicine (PHM) services admitted 449 low-risk patients for a total of 1550 inpatient nights. The percentage of patient nights with overnight vital signs decreased from 98% to 38%. There were no code blues or emergent transfers. CONCLUSION: Our improvement interventions reduced the frequency of overnight vital sign monitoring in 2 low-risk groups without any adverse events.

Occult Injury Screening Among Infants With Subconjunctival Hemorrhage.

PURPOSE: To assess the frequency and nature of occult injury screening in infants with subconjunctival hemorrhages (SCH), the incidence of occult injuries in these children, and the factors that may have influenced the decision to screen for additional injury. METHODS: Infants aged 14 days to 6 months with SCH who presented to two tertiary pediatric centers were identified from a local database (N = 84). A retrospective chart review collected demographics, examination findings, and imaging results. Infants were further stratified into two groups depending on the presence of additional mucocutaneous injuries. The groups were compared with two-sample t testing. RESULTS: Skeletal surveys were completed in 31% of patients overall, but the rate of screening was significantly higher among patients who presented with SCH and additional mucocutaneous injuries as opposed to SCH alone. However, the presence of additional mucocutaneous injuries was not associated with an increased risk for positive skeletal survey. CONCLUSIONS: Rates of occult injury screening among infants with SCH were low and were significantly influenced by the presence of additional injuries. When screening was conducted, occult injuries were commonly identified. Future studies should assess the true prevalence of abuse in this population. [J Pediatr Ophthalmol Strabismus. 2021;58(4):213-217.].

Patient factors associated with documented provision of JNC 7-recommended hypertension care at an academic family medicine office.

BACKGROUND: Little is known about patient factors associated with the provision of hypertension care as recommended by JNC 7. METHODS: We conducted a retrospective chart review (n = 150) to compare documented provision of items recommended by JNC 7 with various patient factors, using a 15-point scoring tool (0% to 100%). RESULTS: The overall documentation of JNC guideline-recommended care was 78.3%. There was a significant effect of marital status; married patients received more guideline-recommended care than unmarried patients (80.4% vs 74.4%; P = .02). Men received more guideline-recommended care than women (80.7% vs 76.4%; P = .02). Multivariate analysis revealed that Medicaid patients had 7.1% lower rates of guideline-recommended care than patients with other insurance (P = .05). There was no significant difference in guideline-recommended care based on race/ethnicity; however, racial/ethnic disparities were identified for certain individual standards. CONCLUSIONS: Hypertension care in 2013 at an academic family medicine center was, for the most part, in agreement with guidelines; however, provision of some items varied based on sex, marital status, and insurance. Awareness of these predictors may help improve the implementation of guidelines, particularly relevant given the recent release of JNC 8.

Correlates of implicit cognitive line length representation in two-dimensional space.

Twenty-eight sex- and age-matched participants, half dextrals and half sinstrals, were instructed to move a pen-sized planometer three inches (7.6 cm) while blindfolded. Under separate trials, movements were made at four angles, towards and away from the body, and at two distances from the body (30 cm, 53 cm). Half were made with the right hand and half with the left hand. Line estimates increased in length across blocks of trials in a linear fashion and progressively overestimated the three-inch imagined criterion. Lines made moving towards the body were longer than those made moving away from the body, implying an egocentric frame of reference in making the estimates. Line estimates made at an oblique angle differed significantly from estimates made at other angles. No influences of sex, handedness, or the hand used in making the estimates were observed. The findings suggest that motoric estimates of line lengths made without visual cues-a unique measure of an implicit cognitive concept-are significantly altered by temporal and spatial factors, but not by sex or hemispheric laterality.