Care coordination for children with a disability or developmental difficulty: Empowers families and reduces the burden on staff supporting them.

BACKGROUND: Almost half of all children and young people with a disability or developmental difficulty (DDD) have complex disability and are likely to require multidisciplinary care. Care coordination (CC) aims to provide a single point of contact and a coordinated service, thereby improving care experiences, meeting unmet needs and empowering families. The impact of CC for children with DDD was evaluated. METHOD: Between May and August 2020, an in-depth evaluation of CC in Gwent, South Wales was conducted. Of 284 families who accessed CC, 38 were approached, as well as 177 health and social care professionals based at Serennu, Nevill Hall and Caerphilly Children's Centres. Nine families and 14 professionals completed semi-structured interviews. Interview transcripts were analysed using thematic analysis. RESULTS: This evaluation found perceived improvements in families' abilities to navigate, organize and understand care and increased parental engagement. Professionals observed fewer missed appointments, and both professionals and families described CC as a source of holistic support, including practical advice regarding housing, finances and emotional support. Professionals commented on CC easing pressure on their service. Potential limitations included restricted staff capacity and the role not being defined clearly for families and professionals. CONCLUSIONS: At a time of increased stress for families of children with DDD, and scarce resources to support them, care coordinators play a vital role in assisting families to engage with health services, while feeling supported and empowered. CC reduces the burden on professionals, while enhancing relationships with families.

Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE: Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)? DESIGN: Prospective comparative longitudinal study. SETTING: Community. PATIENTS: Children <6 years old. INTERVENTIONS: The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases. MAIN OUTCOME MEASURES: Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD. RESULTS: Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%. CONCLUSIONS: These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

"They just get it" an exploration of father's experiences and perceptions of a support group for men caring for children with disabilities and/or developmental delay.

BACKGROUND: Support groups available to parents/carers of children with a disability or developmental delay (DDD) are predominately attended by women. Limited data exists reporting experiences of the few male-only support groups. This paper examines experiences of fathers of children with DDD attending a male-only support group from South Wales. METHOD: All fifteen members from a support group for fathers/male carers of children with DDD were invited to take part in qualitative interviews and seven participated. The data were analysed following Braun and Clarke's (Qualitative research in psychology, 2006, 3:77) thematic framework. RESULTS: Within the group, fathers felt understood by similarly situated men, and a sense of connectivity and belonging. Fathers perceived exclusion elsewhere, including mixed-gender groups. Fathers felt permission to talk in a way consistent with their male identities, and valued receiving, and giving, support. CONCLUSIONS: Mixed-gender support groups may not meet the needs of fathers, and there are potential benefits in providing male-only groups.

Lazarus Syndrome - Challenges Created by Pediatric Autoresuscitation.

ABSTRACT: Pediatric autoresuscitation is extremely rare, with only 4 documented cases in the literature. The longest recorded time between stopping cardio pulmonary resuscitation (CPR) and return of spontaneous circulation is 2 minutes. We report a previously well 18-month-old who attended the emergency department after an unexplained cardiac arrest. After 10 cycles of CPR, resuscitation was stopped; 6 minutes later, the patient had a return of spontaneous circulation and was transferred to the pediatric intensive care unit. The patient remains alive but with significant neurological impairment. There are a variety of theories regarding the pathology of pediatric autoresuscitation. The most commonly accepted model is that there is a degree of autopositive end-expiratory pressure impending venous return as a consequence of vigorous ventilation during CPR. This case challenges clinicians to reassess our current definition of death and reaffirms the need for clearer guidelines surrounding the certification of death.

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

OBJECTIVES: Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age. METHODS: A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis. RESULTS: Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively. CONCLUSION: Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).

What Do Confessions Reveal About Abusive Head Trauma? A Systematic Review.

Although confessions related to abusive head trauma (AHT) are reported, no detailed analysis exists. Therefore, we systematically reviewed studies of AHT confessions and examined the details, including country of origin, mechanisms and perpetrators' characteristics [PUBLISHER - THE PRECEDING UNDERLINED TEXT IS FOR THE MARGIN]. Employing 36 search terms across three search engines, we searched Medline and CINAHL from 1963 to 2018. All relevant studies underwent two independent reviews and data extraction. Descriptive statistics were used to characterise the sample; chi square and Fisher's exact tests were used to assess differences in demographic and clinical characteristics. Of 6759 identified studies, 157 full texts were reviewed and 55 articles from 15 countries spanning four continents were included. Included articles contained 434 confessions. The mechanisms of abuse included shaking alone (64.1%), impact alone (17.1%), shaking plus impact (18.0%) and other (0.9%). There was no statistically significant difference in the percentage of confessions reporting shaking alone when comparing continents: North America (64.0%), Europe (64.2%) and Oceania (60.0%; P=.92), or when comparing circumstances in which the confession was obtained: medical evaluation (74.6%) vs police or judicial investigations (63.4%; P=.11). Of 119 cases with identified perpetrators, 67.2 per cent were cases with males alone. Confessions reveal striking similarities in the mechanism of AHT (predominantly shaking) and occur across the globe.

Incidence of medically attended paediatric burns across the UK.

OBJECTIVE: Childhood burns represent a burden on health services, yet the full extent of the problem is difficult to quantify. We estimated the annual UK incidence from primary care (PC), emergency attendances (EA), hospital admissions (HA) and deaths. METHODS: The population was children (0-15 years), across England, Wales, Scotland and Northern Ireland (NI), with medically attended burns 2013-2015. Routinely collected data sources included PC attendances from Clinical Practice Research Datalink 2013-2015), EAs from Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI, 2014) and National Health Services Wales Informatics Services, HAs from Hospital Episode Statistics, National Services Scotland and Social Services and Public Safety (2014), and mortality from the Office for National Statistics, National Records of Scotland and NI Statistics and Research Agency 2013-2015. The population denominators were based on Office for National Statistics mid-year population estimates. RESULTS: The annual PC burns attendance was 16.1/10 000 persons at risk (95% CI 15.6 to 16.6); EAs were 35.1/10 000 persons at risk (95% CI 34.7 to 35.5) in England and 28.9 (95% CI 27.5 to 30.3) in Wales. HAs ranged from 6.0/10 000 person at risk (95% CI 5.9 to 6.2) in England to 3.1 in Wales and Scotland (95% CI 2.7 to 3.8 and 2.7 to 3.5, respectively) and 2.8 (95% CI 2.4 to 3.4) in NI. In England, Wales and Scotland, 75% of HAs were aged <5 years. Mortality was low with 0.1/1 000 000 persons at risk (95% CI 0.06 to 0.2). CONCLUSIONS: With an estimated 19 574 PC attendances, 37 703 EAs (England and Wales only), 6639 HAs and 1-6 childhood deaths annually, there is an urgent need to improve UK childhood burns prevention.

Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature.

Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.

First aid for children's burns in the US and UK: An urgent call to establish and promote international standards.

INTRODUCTION: Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn. METHODS: A prospective cross-sectional study of 500 children (0-16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015-2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities. RESULTS: Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver. CONCLUSION: A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.

Integration of the Safe Environment for Every Kid (SEEK) Model Across Primary Care Settings.

This project sought to assess the generalizability, barriers, and facilitators of implementing the Safe Environment for Every Kid (SEEK) model for addressing psychosocial risk factors for maltreatment across multiple primary care settings, including a pediatric practice, federally qualified health center, and family medicine practice. The SEEK model includes screening caregivers for psychosocial risk factors at well-child visits age 0 to 5 years, brief intervention incorporating principles of motivational interviewing to engage caregivers, and referral to treatment. All practices successfully implemented SEEK, with screening completion rates from 75% to 93% and brief intervention rates from 61% to 81%. Major parental stress (14%) and food insecurity (11%) were the most common risk factors. Providers found SEEK worthwhile for improving their knowledge, skills, and ability to address psychosocial concerns and provide whole person care. Barriers included limited time and resources, incomplete resource knowledge, and lack of follow-up. Facilitators included on-site support staff to assist with communication and referrals.

Factors influencing child protection professionals' decision-making and multidisciplinary collaboration in suspected abusive head trauma cases: A qualitative study.

Clinicians face unique challenges when assessing suspected child abuse cases. The majority of the literature exploring diagnostic decision-making in this field is anecdotal or survey-based and there is a lack of studies exploring decision-making around suspected abusive head trauma (AHT). We aimed to determine factors influencing decision-making and multidisciplinary collaboration in suspected AHT cases, amongst 56 child protection professionals. Semi-structured interviews were conducted with clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We identified six themes influencing decision-making: 'professional', 'medical', 'circumstantial', 'family', 'psychological' and 'legal' factors. Participants diagnose AHT based on clinical features, the history, and the social history, after excluding potential differential diagnoses. Participants find these cases emotionally challenging but are aware of potential biases in their evaluations and strive to overcome these. Barriers to decision-making include lack of experience, uncertainty, the impact on the family, the pressure of making the correct diagnosis, and disagreements between professionals. Legal barriers include alternative theories of causation proposed in court. Facilitators include support from colleagues and knowledge of the evidence-base. Participants' experiences with multidisciplinary collaboration are generally positive, however child protection social workers and police officers are heavily reliant on clinicians to guide their decision-making, suggesting the need for training on the medical aspects of physical abuse for these professionals and multidisciplinary training that provides knowledge about the roles of each agency.

Acceptability of the Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A qualitative study with child protection professionals.

The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) based on combinations of six clinical features: head/neck bruising; apnea; seizures; rib/long-bone fractures; retinal hemorrhages. We aimed to determine the acceptability of PredAHT to child protection professionals. We conducted qualitative semi-structured interviews with 56 participants: clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We explored participants' evaluations of PredAHT, their opinions about the optimal way to present the calculated probabilities, and their interpretation of probabilities in the context of suspected AHT. Clinicians, child protection social workers and police thought PredAHT would be beneficial as an objective adjunct to their professional judgment, to give them greater confidence in their decisions. Lawyers and pathologists appreciated its value for prompting multidisciplinary investigations, but were uncertain of its usefulness in court. Perceived disadvantages included: possible over-reliance and false reassurance from a low score. Interpretations regarding which percentages equate to 'low', 'medium' or 'high' likelihood of AHT varied; participants preferred a precise % probability over these general terms. Participants would use PredAHT with provisos: if they received multi-agency training to define accepted risk thresholds for consistent interpretation; with knowledge of its development; if it was accepted by colleagues. PredAHT may therefore increase professionals' confidence in their decision-making when investigating suspected AHT, but may be of less value in court.

Intimate partner violence victimization and parenting: A systematic review.

Early studies examining parenting in the setting of intimate partner violence (IPV) often focus on abuse by the IPV perpetrator or effects of long term exposure. This review addresses how intimate partner violence impacts victim parenting. Seven databases were searched for the time period 1970-2015. Included were comparative studies involving children 11 years or younger. Quality ranking was based on: confirmation of victim status, consideration of co-perpetration, heterogeneity of the population, and standardization of measurements. Of 13,038 studies reviewed, 33 included studies showed that victimization is associated with negative parenting practices. Based on data presented within individual studies, 21 studies were eligible for meta-analysis which demonstrated modest effect sizes with high levels of heterogeneity. There was a negative correlation between IPV and positive parenting (r = -0.08; 95% CI: -.12, - .04); positive correlation between IPV and physical aggression (r = .17; 95% CI: .11, .23) and neglect (r = .12; 95% CI: .01, .23); and a trend toward positive correlation between IPV and psychological aggression (r = .23; 95% CI: -.94, .47). A synthesis of studies unsuitable for meta-analysis reinforced these findings. The review demonstrated ongoing methodological issues with extant literature.

Abusive head trauma and the triad: a critique on behalf of RCPCH of 'Traumatic shaking: the role of the triad in medical investigations of suspected traumatic shaking'.

The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) has recently published what they purported to be a systematic review of the literature on 'isolated traumatic shaking' in infants, concluding that 'there is limited evidence that the so-called triad (encephalopathy, subdural haemorrhage, retinal haemorrhage) and therefore its components can be associated with traumatic shaking'. This flawed report, from a national body, demands a robust response. The conclusions of the original report have the potential to undermine medico-legal practice. We have conducted a critique of the methodology used in the SBU review and have found it to be flawed, to the extent that children's lives may be put at risk. Thus, we call on this review to be withdrawn or to be subjected to international scrutiny.

Clinical characteristics of children presenting with a suspicion or allegation of historic sexual abuse.

INTRODUCTION: Police-recorded sexual offences against children and young people (CYP) increased 85% in the UK between 2010/2011 and 2014/2015. Many children delay disclosure, but little data are available regarding characteristics of CYP presenting with historic child sexual abuse (CSA). AIM: To identify the clinical and CSA-related characteristics of CYP presenting with a suspicion or allegation of historic CSA. METHOD: Data were collected on all CYP<17 years presenting with suspected or alleged historic CSA (ie, >3 days since last sexual assault in prepubertal children, >7 days pubertal girls) between October 2009 and November 2014. DATA COLLECTED: source and indication for referral, alleged perpetrator, physical findings. Findings supportive of CSA were peer reviewed for consensus agreement. ANALYSIS: χ2 test, Fisher's exact test and logistic regression. RESULTS: Among 249 CYP, presentation with physical/behavioural symptoms was associated with age <13 years (p<0.01), and alleged penetration with ages 13-17 years (p<0.01). Where known, time since alleged CSA ranged from 1 week to 13 months. Anogenital findings supportive of CSA were present in 7% of examined children (16/233), significantly associated with alleged penetration (p<0.01) and more likely with increasing age (OR 1.46, 95% CI 1.23 to 1.72). Additionally, where tested, sexually transmitted infections (STI) were detected in 2.6% CYP (3/116). Alleged perpetrators were intrafamilial in 66% (126/190). No associations were identified between perpetrator type and gender (p=1.0), age (p=0.7) or indication for referral (p=0.35). CONCLUSIONS: Despite significant time delay since the alleged CSA, this study highlights the persistence of anogenital findings supportive of CSA in 7% and STIs in 2.6% of CYP.

Raising suspicion of maltreatment from burns: Derivation and validation of the BuRN-Tool.

BACKGROUND: 10-25% of childhood burns arise from maltreatment. AIM: To derive and validate a clinical prediction tool to assist the recognition of suspected maltreatment. METHODS: Prospectively collected data from 1327 children with burns were analyzed using logistic regression. Regression coefficients for variables associated with 'referral for child maltreatment investigation' (112 cases) in multivariable analyses were converted to integers to derive the BuRN-Tool, scoring each child on a continuous scale. A cut-off score for referral was established from receiver operating curve analysis and optimal sensitivity and specificity values. We validated the BuRN-Tool on 787 prospectively collected novel cases. RESULTS: Variables associated with referral were: age <5years, known to social care, concerning explanation, full thickness burn, uncommon body location, bilateral pattern and supervision concern. We established 3 as cut-off score, resulting in a sensitivity and specificity for scalds of 87.5% (95% CI:61.7-98.4) and 81.5% (95% CI:77.1-85.4) respectively and for non-scalds sensitivity was 82.4% (95%CI:65.5-93.2) and specificity 78.7% (95% CI:73.9-82.9) when applied to validation data. Area under the curve was 0.87 (95% CI:0.83-0.90) for scalds and 0.85 (95% CI:0.81-0.88) for non-scalds. CONCLUSION: The BuRN-Tool is a potential adjunct to clinical decision-making, predicting which children warrant investigation for child maltreatment. The score is simple and easy to complete in an emergency department setting.

Childhood bruising distribution observed from eight mechanisms of unintentional injury.

OBJECTIVE: To inform the assessment of described mechanisms of bruising in children. DESIGN: Prospective cross-sectional study. SETTING: The emergency department, and children in the local community. PATIENTS: Children aged 0-13 years with bruises from unintentional injuries. EXCLUSIONS: bleeding disorder, medication affecting coagulation or child protection concerns. INTERVENTIONS: Injury incidents were categorised into one of eight causal mechanisms (fall from<1 m, 1-2 m, fall from standing height or less and hitting an object during fall, stairs or impact, crush, sports or motor vehicle collision). MAIN OUTCOME MEASURES: Location, number and mechanism of bruising for each injury mechanism. RESULTS: 372 children had 559 injury incidents, resulting in 693 bruises; 85.2% of children were walking independently, with impact injuries and fall from standing height (including hitting an object) being the predominant mechanisms. A single bruise was observed in 81.7% of all incidents. Stair falls resulted in ≥3 bruises only with falls involving ≥10 steps (6/16). Bruising was rarely observed on the buttocks, upper arm, back of legs or feet. No bruises were seen in this dataset on ears, neck or genitalia. Petechial bruising was only noted in 1/293 unintentional incidents, involving a high-impact injury in a school-aged child. CONCLUSION: These findings have the potential to aid an assessment of the plausibility of the explanation given for a child with bruising. Certain bruise distributions were rarely observed, namely multiple bruises from a single mechanism, petechiae and bruising to the ears, neck or genitalia.