Child Fatality Review.

Understanding why children die is necessary to implement strategies to prevent future deaths and improve the health of any community. Child fatality review teams (CFRTs) have existed since the 1970s and provide a necessary framework to ensure that proper questions are asked about a child's death. CFRTs provide a vital function in a community to ensure that preventable causes of deaths are identified. Pediatricians are necessary members of CFRTs because they provide medical expertise and context around a child's death. All CFRTs should have pediatric physician representation, and results from team meetings should inform public policy at all levels of government. Pediatricians should be supported in their efforts to be present on CFRTs, and they should use data from team meetings to help advocate for implementing prevention strategies.

Addressing Systemic Racism in the American Professional Society on the Abuse of Children Publications.

The United States continues to grapple with longstanding policies and systems that have adversely impacted historically marginalized communities who identify (and are racialized) as non-White. These stem from a legacy of structural and systemic racism, and the long-term consequences of sanctioned colonization. This legacy rests upon a field of scholarly research that is similarly fraught with white supremacy. As a field, we must examine the process of producing and publishing the body of evidence that has codified harmful policies and practices. Although racial and ethnic disparities have been discussed for decades in the child welfare and health systems, systemic racism has received comparatively little attention in academic research and journals. In this commentary, the authors detail concrete steps over the coming years that will advance diversity, equity, inclusion and justice through American Professional Society on the Abuse of Children's (APSACs) flagship journal, Child Maltreatment. The journal is committed to anti-racist publication processes, such that the journal pledges to develop procedures, processes, structures, and culture for scholarly research that promotes diversity, equity, inclusion, and justice in all forms.

Our Commitment to Promoting Diversity, Equity, Inclusion, and Justice in Child Maltreatment.

In this commentary, the editorial team of Child Maltreatment extends and expands on APSAC's position on diversity, equity, inclusion, and justice, affirms our commitment and plans for addressing these issues in this publication, and highlights articles in this issue that continue the discussion about race and racism in the child welfare and child protection systems.

Social and demographic characteristics of child maltreatment fatalities among children ages 5-17 years.

BACKGROUND: While risk factors have been identified among infants and young children, less is known about child maltreatment fatalities among older children. OBJECTIVES: To describe the social and demographic characteristics of children where abuse or neglect was determined to cause or contribute to their death, compare characteristics and circumstances of the deaths by cause and manner of death and type of maltreatment, and explore the role of abuse and neglect in child suicides. PARTICIPANTS AND SETTING: Secondary analysis of deaths due to child abuse or neglect among children ages 5-17 years old occurring during 2009-2018 and documented in the National Fatality Review-Case Reporting System. METHODS: Child, family, and social characteristics were compared by child age (5-10 years vs. 11-17 year-olds), and by cause and manner of death. Frequencies and proportions were reported and compared using chi-square statistics. RESULTS: 1478 maltreatment-related deaths were identified. Higher proportions of older children were non-Hispanic white, had a history of chronic disease or disability, had problems in school, and had a history of mental health issues. Forty-three percent of the maltreatment deaths were due to homicide and 10 % by suicide. Higher proportions (65 %) of younger children (5-10 years old) died by homicide, compared to older children (35 % among ages 11-17y). While 58 % of deaths overall were related to neglect, 68 % of deaths in older children were related to neglect, including 80 % of suicides. CONCLUSIONS: The causes of child maltreatment deaths among children 5-17y vary by age. Child neglect caused and/or contributed to most child suicides.

Role of Psychologists in Child Abuse Pediatrics.

This article describes the extent of the problem and the medical evaluation of child maltreatment, focusing on the outpatient interdisciplinary assessment of suspected child physical and sexual abuse. Separate from their role as clinicians, the roles of the child psychologist before, during, and after the medical assessment are highlighted. The child psychologist is an important member of the interdisciplinary team who helps the team prepare for the evaluation (before), assists in screening and determining immediate psychological safety during the medical evaluation (during), and communicating the need for further treatment and follow-up (after).

Preventing intimate partner violence among foreign-born Latinx mothers through relationship education during nurse home visiting.

AIMS: This study aimed to examine the effectiveness of an augmented home visiting programme in preventing intimate partner violence among Latinx mothers by nativity. BACKGROUND: Intimate partner violence diminishes home visit programmes' effectiveness. Immigrant Latinx mothers are especially vulnerable and need culturally tailored prevention. METHODS: We performed secondary analyses of 33 US-born and 86 foreign-born Latinx mothers at baseline and 1- and 2-year follow-up in a longitudinal randomized controlled trial of the Nurse-Family Partnership programme augmented with nurse-delivered Within My Reach relationship education curriculum and violence screening and referrals in Oregon. We estimated proportional odds models via generalized estimating equations on total physical and sexual victimization and/or perpetration forms (an ordinal variable), adjusting for intervention, wave, age and education. RESULTS: The intervention-nativity interaction was not significant (p = .953). Foreign-born status was associated with lower reported violence at baseline (adjusted odds ratio: 0.29, 95% confidence interval: 0.13-0.67, p = .004). This association was marginally significant at 1-year follow-up (0.43, 0.17-1.08, p = .072) and not significant at 2-year follow-up (0.75, 0.33-1.67, p = .475). CONCLUSIONS: This augmented programme was not effective for Latinx mothers by nativity. Their nativity gap diminished over time. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leaders should support culturally tailored home visiting programmes to detect and prevent intimate partner violence affecting Latinx immigrants. CLINICAL TRIAL REGISTRATION: This study is registered at www. CLINICALTRIALS: gov NCT01811719. The full trial protocol can be accessed at https://clinicaltrials.gov/ct2/show/NCT01811719.

Factors related to medical neglect recurrence and foster care and adoption services.

BACKGROUND: Medical neglect is defined as the failure of a caretaker to heed obvious signs of serious illness, to seek medical care in a timely fashion, or to follow instructions once medical advice is obtained. It is reportable as a form of child maltreatment. OBJECTIVES: (1) identify factors associated with referrals after medical neglect to adoption and foster care services; (2) describe a cohort of children with first-time cases; and (3) assess whether there were factors associated with recurrence. PARTICIPANTS AND SETTING: Data from the National Child Abuse and Neglect Data System for 36 U.S. states. METHODS: A cohort of children was constructed with first confirmed reports of medical neglect in 2012 with matched confirmed reports during 2012-2017 to describe child, family, offender, and report factors associated with recurrence. These factors were then used in multivariate models, including logistic regression and Cox proportional hazard models, to assess their effects on recurrence and with referral to foster care and adoption services. RESULTS: Complex family problems were associated with referral for foster care and adoption services, and 8.1% had recurrence within 5 years. Older children with medical problems, Black race, or who were reported by medical or legal personnel had increased risk for recurrence. Only referral to mental health care services was found to decrease this risk. CONCLUSIONS: Medical neglect recurs within 5 years despite referrals to most services. Those trying to stop its recurrence should focus on mental health needs and families with children who are older, Black, or have complex medical problems.

Improving Physical Abuse Documentation and Photography through a Remote Peer Review Intervention.

Child Abuse Pediatrics is a small and geographically dispersed specialty. This article reports on an intervention to improve written and photodocumentation quality and uniformity in suspected child physical abuse cases, using a remote, de-identified case review system. METHODS: In each cycle, participants submitted de-identified medical reports and photographs for review by a child abuse pediatrics expert. Experts evaluated 3 cycles of 5 cases using a novel rubric and assigned quality interventions for the participants based on their scores. RESULTS: 15 of 16 participants improved scores between cycles 1 and 3 (78% versus 89%, P < 0.001). All participants rated the program as helpful and would recommend it to a colleague. CONCLUSION: A quality improvement project administered via the internet improves the quality and uniformity of written and photographic documentation in child physical abuse evaluations.

Half Century Since SIDS: A Reappraisal of Terminology.

After a sudden infant death, parents and caregivers need accurate and open communication about why their infant died. Communicating tragic news about a child's death to families and caregivers is difficult. Shared and consistent terminology is essential for pediatricians, other physicians, and nonphysician clinicians to improve communication with families and among themselves. When families do not have complete information about why their child died, pediatricians will not be able to support them through the process and make appropriate referrals for pediatric specialty and mental health care. Families can only speculate about the cause and may blame themselves or others for the infant's death. The terminology used to describe infant deaths that occur suddenly and unexpectedly includes an assortment of terms that vary across and among pediatrician, other physician, or nonphysician clinician disciplines. Having consistent terminology is critical to improve the understanding of the etiology, pathophysiology, and epidemiology of these deaths and communicate with families. A lack of consistent terminology also makes it difficult to reliably monitor trends in mortality and hampers the ability to develop effective interventions. This report describes the history of sudden infant death terminology and summarizes the debate over the terminology and the resulting diagnostic shift of these deaths. This information is to assist pediatricians, other physicians, and nonphysician clinicians in caring for families during this difficult time. The importance of consistent terminology is outlined, followed by a summary of progress toward consensus. Recommendations for pediatricians, other physicians, and nonphysician clinicians are proposed.

Risk Factors for Child Maltreatment Fatalities in a National Pediatric Inpatient Database.

BACKGROUND AND OBJECTIVES: Child maltreatment (CM) is recognized as a major public health concern, and an important number of children suffer injuries related to abuse and neglect that result in death. We sought to identify risk factors for CM fatalities among hospitalized children that can provide clinicians with information to recognize at-risk children and reduce further death. METHODS: In this study, we included cases from the 2012 Kids' Inpatient Database with diagnosis codes related to CM who were <5 years of age and were not transferred to another facility. Potential demographic and clinical risk factors were identified and compared to child fatality in the hospital by using bivariate and multivariate analyses. To assess how cases coded specifically for maltreatment differed from similar cases that only suggested maltreatment, a reduced-model multivariable logistic regression for fatality was created. RESULTS: We found 10 825 children <5 years who had inpatient diagnoses coded in their medical record for CM. Most demographic variables (age, race, and sex) were not significantly associated with fatality, whereas clinical variables (transferring in, drowning, ingestions, and burns) were significantly associated with fatality. There were regional differences on the basis of hospital location as well as significantly more chronic conditions, procedure charges, and longer lengths of stay among children who died. Controlling for significant risk factors, those with diagnoses specific for physical abuse had ∼3 times the odds of dying (odds ratio = 2.797; 95% confidence interval: 1.941-4.031). CONCLUSIONS: In this study, although infancy and decreased income were associated with increased risk for fatality, more important factors were the types of injuries the child endured and whether the inpatient clinician had identified specific injuries indicating physical abuse.

Pediatric Fingertip Injuries: Association With Child Abuse.

Purpose: Pediatric fingertip injuries are most commonly reported in the setting of an accidental occurrence. The purpose of this study was to determine whether there is an association of child abuse and neglect with pediatric fingertip injuries. Methods: The New York Statewide Planning and Research Cooperative System (2004 to 2013) administrative database was used to identify children aged 0 to 12 years who presented in the inpatient or outpatient (emergency department or ambulatory surgery) setting. International Classification of Diseases, Ninth Revision diagnosis codes were used to identify fingertip injuries (amputation, avulsion, or crushed finger) and abuse. Cohort demographics of children presenting with fingertip injuries were described. We analyzed the association between fingertip injuries and child abuse using multivariable logistic regression, with variables for insurance status, race, ethnicity, sex, and behavioral risks including depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism. Results: Of the 4,870,299 children aged 0 to 12 years in the cohort, 79,108 patients (1.62%) during the study period (2004 to 2013) presented with fingertip injuries. Of those with a fingertip injury, 0.27% (n = 216) presented either at that visit or in other visits with a code for child abuse, compared with 0.22% of pediatric patients without a fingertip injury (n = 10,483). In an adjusted analysis, the odds of a fingertip injury were 23% higher (odds ratio [OR] = 1.23; 95% confidence interval [CI], 1.07-1.41) for children who had been abused, compared with those who had not. Patients were more likely to present with fingertip injuries if they had ever had Medicaid insurance (OR = 1.40; 95% CI, 1.37-1.42) or had a behavioral risk factor (OR = 1.35; 95% CI, 1.30-1.40). Conclusions: Patients presenting with abuse are significantly more likely to have fingertip injuries during childhood compared with those without recorded abuse, which suggests that these injuries may be ones of abuse or neglect. Medicaid insurance, white race, and behavioral diagnoses of depression, attention-deficit hyperactivity disorder, aggressive behavior, and autism were also associated with increased odds of presenting with fingertip injuries. Type of study/level of evidence: Prognostic III.

Risk Factors and Services to Reduce Child Sexual Abuse Recurrence.

Child sexual abuse (CSA) is associated with a range of negative consequences for victims that are compounded when it recurs. We used the National Child Abuse and Neglect Data System to study a cohort of 42,036 children in 45 U.S. states with sexual abuse reports first confirmed by child protective services (CPS) during 2010 in order to identify children with increased risk for recurrence. A small proportion (3.6%) had a second confirmed sexual abuse report through 2015. In multivariate models, female gender, family hearing and vision problems, other child maltreatment, and other family violence were associated with increased risk of recurrence, while younger children, Hispanic families, and those with substance abuse tended to have less risk. One fourth of recurrence involved the same offender, usually a parent or caretaker. One fourth of cases were referred for any CPS services, which were more likely to be provided for families with poverty, drug or alcohol problems, or other violence. Only substance abuse services significantly reduced recurrence in multivariable models. Those trying to reduce CSA recurrence should recognize that certain case characteristics are associated with greater recurrence, and most CPS services do not significantly reduce CSA recurrence.

Identifying Child Abuse Fatalities During Infancy.

When a healthy infant dies suddenly and unexpectedly, it is critical to correctly determine if the death was caused by child abuse or neglect. Sudden unexpected infant deaths should be comprehensively investigated, ancillary tests and forensic procedures should be used to more-accurately identify the cause of death, and parents deserve to be approached in a nonaccusatory manner during the investigation. Missing a child abuse death can place other children at risk, and inappropriately approaching a sleep-related death as maltreatment can result in inappropriate criminal and protective services investigations. Communities can learn from these deaths by using multidisciplinary child death reviews. Pediatricians can support families during investigation, advocate for and support state policies that require autopsies and scene investigation, and advocate for establishing comprehensive and fully funded child death investigation and reviews at the local and state levels. Additional funding is also needed for research to advance our ability to prevent these deaths.

Interpreting Osteogenesis Imperfecta Variants of Uncertain Significance in the Context of Physical Abuse: A Case Series.

Unexplained childhood fracture(s) warrant consideration of physical abuse and osteogenesis imperfecta (OI). Genetic OI testing may identify "variants of unknown significance (VUS)." Interpretation of VUS in context of potential abuse may have protective, criminal, and medical impacts. This case series explores practices regarding clinicians' interpretation of VUS during child abuse evaluations. Variability was noted regarding factors considered for interpreting clinical significance. Based on these cases, recommendations for careful and thorough evaluation are detailed, including proposed use of a limited follow-up skeletal survey in 3 months, as a consideration to assess healing of prior fractures and to look for any additional injuries.

Correction to: A consensus response on the complete picture: reply to Lynøe and Eriksson.

The original version on this paper contained an error. The COI statement is incorrectly presented.