Identification and Incidence of Child Maltreatment During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has raised serious concerns about child maltreatment, which is known to increase in frequency and severity during times of high stress. The present study used diverse datasets to concurrently examine changes in identification and medical evaluation of maltreatment allegations from before to during COVID-19. Four sources of data were collected from two counties for the months of March-December in 2019 and 2020, including reports to social services and child maltreatment evaluation clinic medical evaluations (CMECs). The number of reports, number of children reported, and rate of children reported were used to evaluate identification. Incidence was estimated based on the number of medical evaluations conducted at the CMECs. Maltreatment type, reporter type, and child demographics were also considered. Across both counties, there were significantly fewer reports and reported children in 2020 compared to 2019, signifying decreased identification of suspected maltreatment cases. This was especially true in spring and fall when children are typically in school. Across both counties, the proportion of children reported to the county that received medical evaluations was higher in 2020 compared to 2019. This suggests that the pandemic was related to an increase in the occurrence maltreatment serious enough to warrant medical evaluations, or perhaps in the relative number of serious cases identified. Findings show divergent trends in reporting and evaluation of suspected maltreatment cases from before to during COVID-19. Identification and service delivery methods need creative solutions to adapt to changing environments. Medical, social, and legal systems need to prepare for increases in families seeking services as pandemic-related restrictions are lifted.

Fatal Transdermal Fentanyl Patch Overdose in a Child.

A previously healthy three-year-old girl was brought into the emergency department by ambulance after being found unresponsive with a family member's fentanyl patch found adherent to her lower back. A head CT scan showed global cerebral edema and the patient progressed to brain death. An initial standard urine drug screen was negative for opiates, however, subsequent specific urine assay testing was found to be positive for fentanyl and norfentanyl. This case highlights the dangers of not properly disposing of used fentanyl patches as they may still contain enough fentanyl to cause respiratory failure and subsequent unintentional death in children. Prescribing physicians and pediatricians should advise care providers that fentanyl patches should be carefully stored, monitored, and disposed of properly in order to prevent accidental exposure to the pediatric population. Furthermore, synthetic opiates such as fentanyl will not read as positive on routine urine drug screens and will require specific urine assays.

A novel mutation in the proopiomelanocortin (POMC) gene of a Hispanic child: metformin treatment shows a beneficial impact on the body mass index.

Background Proopiomelanocortin (POMC) is a complex polypeptide that produces a variety of biologically active substances via cleavage in a tissue-specific manner [Challis BG, Millington GW. Proopiomelanocortin deficiency. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle, 1993-2018], yielding several products including adrenocorticotrophic (ACTH) and melanocyte stimulating hormones (MSH). These peptides have roles in the regulation of food intake, energy homeostasis, adrenal steroidogenesis, melanocyte stimulation and immune modulation. Rare mutations in the POMC gene can lead to ACTH deficiency and thus isolated hypocortisolism. The first cases of POMC mutation were documented by Krude et al. in 1998 [Krude H, Biebermann H, Luck W, Horn R, Brabant G, et al. Severe early-onset obesity, adrenal insufficiency and red hair pigmentation caused by POMC mutations in humans. Nat Genet 1998;19:155-7]. Mutations in the POMC gene were linked with a clinical phenotype of adrenal insufficiency, red hair pigmentation, early onset and rapidly progressive obesity, early onset type 2 diabetes, hypothyroidism, hypogonadism and growth hormone deficiency. Case presentation We describe a prepubertal Hispanic boy with a novel homozygous POMC mutation with severe obesity, hypothyroidism, adrenal insufficiency and abnormal reddish hair pigmentation. The patient presented as a 2-year-old with exponential weight gain, abnormal thyroid labs and speech delay. Laboratory testing demonstrated central adrenal insufficiency and genetic testing confirmed a homozygous mutation (nucleotide change c.20_21ins25) in exon 3 of the POMC gene. Replacement therapy with thyroid hormone and hydrocortisone was coupled to a slight decrease in the rate of weight gain, although hyperphagia persisted. Parent-directed nutrition and activity education as well as attempts to restrict access to food resulted in a plateau of the body mass index (BMI). At 4 years of age, metformin treatment was initiated with the patient showing evolving signs of insulin resistance and failure of lifestyle/dietary intervention to adequately decrease the BMI. Over a 3-year metformin treatment span, the BMI decreased from 34.9 kg/m2 to 32.9 kg/m2. Conclusions We demonstrate a possible role for metformin in stemming progressive weight gain, thereby impacting the early onset obesity due to hyperphagia.