Andrea M. Vandeven

Update on childhood sexual abuse.

Purpose of review Childhood sexual abuse (CSA) is a problem of epidemic proportion affecting children and communities worldwide. This review will examine the most recent published CSA literature emphasizing not only new findings in diagnosis, management, and prevention, but also practice implications for the medical and community-based provider. Sexual assault and rape, though forms of sexual abuse, are broader than the scope of this article and not discussed in detail at this time. Recent findings Prevalence rates for CSA are difficult to obtain. To identify populations at greatest risk and tailor treatment and prevention initiatives, consistent methods for defining and reporting cases of CSA are needed. Appreciating the quality and quantity of adverse health outcomes associated with CSA has helped clinicians and community providers expand and develop treatment programs. The physical and psychological late effects of abuse can be permanent and life threatening and the primary care provider should assess for mental health problems as well as physical maladies in all routine examinations. Children do not often disclose experiences of abuse for months to years and caregivers must be cognizant of the medical and behavioral indicators that signal early abuse. Child advocacy centers are community-based programs that incorporate medical, psychological, and legal support services for children and their families. This therapeutic model is based on a multidisciplinary team assessment aimed at decreasing stress, providing adequate protection and services for the child, and optimizing chances for a successful legal outcome. Summary While prevention remains the ultimate goal, improved awareness and education for communities and professionals alike is required to ensure appropriate and quality care for all children who are sexually abused.

Update on Munchausen syndrome by proxy

Purpose of review Munchausen syndrome by proxy (MBP) is a complicated form of child maltreatment. Difficulties remain in properly defining the condition, as well as in detection and differentiation from organic illness. This review will discuss the epidemiology and diagnosis of MBP, as well as the role of the physician in sorting out these cases. Recent findings Several recent case studies, including two in which children were diagnosed with celiac disease, add to our knowledge of the protean manifestations of MBP. There is growth in our understanding of how sudden infant death syndrome (SIDS) and the symptom complex seen in acute life-threatening events (ALTEs) may in fact represent manifestations of MBP. Recent legal issues in the United Kingdom pose concern for all physicians engaged in child protection work. Summary In spite of these challenges, the high mortality and recidivism rates associated with MBP make it imperative that pediatricians be familiar with the condition, the subtle signs and symptoms with which it may present, and methods to best protect the children in their care.

Update on child maltreatment.

Purpose of review The authors explore the literature published in the past year addressing child maltreatment issues, including sexual abuse, physical child abuse, inflicted head trauma, and child abuse prevention. Recent findings The body of knowledge about child abuse and its mimics continues to expand. Evident in this years literature is the challenge which the diagnosis of child abuse creates for clinicians. Although further strides are being made toward universal education of providers, it is clear that there is still a reluctance to report abuse to child welfare agencies. The legal repercussions of diagnosing abuse can be extensive, and there has been a proliferation of medical defense experts who disagree with the commonly accepted tenets of abusive injury and who are vocal in the literature. Summary It remains the responsibility of pediatric providers to consider child maltreatment in the differential diagnosis of any unexplained injury or medical problem. Several studies document the high rate of spanking, slapping or shaking children, and primary care clinicians may be the first professionals in a position to begin the evaluation for possible child maltreatment. Despite the natural hesitancy to diagnose abuse, clinicians have an ethical and moral obligation to address this issue both in their practice and in their communities. The short-term and long-term costs to individuals who experience family violence have been well demonstrated and include not only emotional repercussions, but also chronic health conditions, which result in significant cost to society.

Update on child maltreatment with a special focus on shaken baby syndrome.

Purpose of review The many forms of child maltreatment exact an unacceptably heavy toll on our children. Recent work exploring the risk factors for child abuse and neglect, long-term consequences of child maltreatment, and potential for primary prevention will be reviewed. In the past year there have been many notable contributions in the field of shaken baby syndrome that have deepened our understanding of this devastating form of child abuse. Recent findings Evidence of the long-term sequelae of child abuse and neglect continues to accumulate, but with increased understanding of the clinical manifestations of child maltreatment has come greater ability to intervene early and perhaps improve long-term outcomes. Although the effectiveness of some home visiting programs to prevent child maltreatment is coming into question, rigorous review of program components is helping to improve quality. There remain controversies in the diagnosis of shaken baby syndrome but several carefully done case-series are clarifying our knowledge of the myriad presentations of this form of non-accidental head trauma. Summary Pediatricians have an important role to play in the prevention and recognition of child maltreatment.

Unexplained infant and child death: a review of Sudden Infant Death Syndrome, Sudden Unexplained Infant Death, and child maltreatment fatalities including shaken baby syndrome

Purpose of review This review will examine the most recent published literature on Sudden Infant Death, Sudden Unexplained Infant Death, infant and child death due to maltreatment, and Shaken Baby Syndrome. Recent findings New recommendations from the American Academy of Pediatrics about the evaluation and prevention of possible Sudden Infant Death Syndrome cases were published this year, with a focus not only on the Back to Sleep campaign, but other factors that may contribute to the risk of Sudden Infant Death Syndrome. Additionally, the controversial issue of bed sharing is addressed, with advice given not to bed share in the first 3 months of life. The possibility of a second sudden infant death within a family is discussed. Attention is also paid to the importance of considering inflicted injury in the differential diagnosis of every unexplained infant or child death, and the recent literature on child maltreatment deaths is reviewed. Summary The grieving family who has lost an infant should receive immediate attention and support, and a multidisciplinary investigation team should be involved as soon as possible so that a full investigation can take place. Investigation of unexplained infant or child death should always involve a thorough interview with all adults involved, as well as a proper scene investigation and post-mortem examination.

Update on child physical abuse, sexual abuse, and prevention

Purpose of review The most recent literature regarding assessment and management of child maltreatment will be considered. The current status of abuse prevention activity will also be reviewed. Recent findings Clinical practice continues to be burdened by the general lack of training and knowledge of the presenting signs and symptoms of child maltreatment by general practitioners. The need for better training is emphasized. Physician engagement in child protection is further inhibited by imprecise reporting obligations and an inadequate child protective services response by the state. Several randomized, controlled trials of home-visiting programs by professionals have demonstrated modest effects in the primary prevention of child abuse and neglect; however, the prevention of recurrent maltreatment of children who remain in the home has proved elusive. Summary Current clinician training in child maltreatment is inadequate. Research into effective education of clinicians and program effectiveness is plainly needed, and should be supported by increased funding.

The Role of the Medical Provider in the Evaluation of Sexually Abused Children and Adolescents.

It was only 30 years ago that the medical community began to develop an increased awareness of child sexual abuse, and the role of the medical provider in the evaluation of sexually abused children has evolved significantly. As clinicians worldwide develop a greater understanding of the impact of the sexual abuse evaluation on the child, the roles of the physician and nurse have changed. In the United States, current practice often uses a multidisciplinary assessment involving skilled forensic interviewing of the child and a medical examination done by a medical provider with specialized training in sexual abuse. In order to minimize child interviews, these assessments are frequently held in settings such as child advocacy centers, where forensic interviewers and medical clinicians, child protective service workers, and police and district attorneys can work jointly to address the legal and protective issues in a coordinated fashion.

Child abuse and neglect: a worldwide concern

Purpose of review As knowledge about child abuse and neglect increases worldwide, so does the literature on abuse and neglect. The authors explore many studies published this year, with attention to the advances in understanding which are guiding prevention efforts as well as diagnosis and treatment of abuse and neglect. Recent findings The evidence base for many forms of child abuse continues to grow. Controversy around the diagnosis of child abuse still continues, with current debate focused on the diagnosis of abusive head injury and whether children with vitamin D deficiency are misdiagnosed with abusive fractures. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented, and researchers are evaluating these efforts with an eye to whether or not they really contribute to prevention. Summary The short-term and long-term impact of child maltreatment is significant not only for individuals but for families and communities in which abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children. However, it is clear that specialists in child abuse should also play a role in order for diagnosis and management of abuse to adhere to a high standard of care. This has been validated this year by the creation of Child Abuse Pediatrics as a board certified specialty in the United States. As knowledge about abuse and neglect grows, clinicians are focusing on prevention as well as diagnosis and treatment.

Update on child maltreatment: toward refining the evidence base

Purpose of review This review is designed to aid general pediatricians as they assess cases of possible child maltreatment. The authors have selected salient articles that inform the daily practice of any professional involved in assessing child abuse. Recent findings The incidence of child abuse continues to decline in the United States, although a large number of children still suffer from abuse and neglect, and many are subject to more than one type of maltreatment. Clinicians are encouraged to be vigilant about the subtle indicators of physical abuse, with many authors adding to our understanding about how children present after inflicted abdominal or skeletal trauma. Clinicians are also cautioned to watch for signs of Munchausen syndrome by proxy, which may be elusive and difficult to discern. Summary The field of child abuse pediatrics is still young, with the first board certification in 2009. The volume of research in the field is exploding and there is a greater level of awareness and data collection occurring throughout the world. Pediatric clinicians are encouraged to play a role in preventing abuse and neglect, as well as addressing intimate partner violence, and to maintain vigilance about child maltreatment and its subtle clinical presentations.

Bone Marrow Donation Between Siblings Living in Different Families

Minor siblings are often considered as potential bone marrow donors when a child needs a bone marrow transplant. The practice of using minors as bone marrow donors is ethically controversial, because there is some risk to the donor—and some pain and suffering—but no medical benefit. Nevertheless, most courts and most ethics committees have sanctioned bone marrow donation procedures as long as the donor and the recipient are in the same family and have an emotional tie. Presented here is a case that pushes the limits of those criteria; we asked Drs Doug Diekema, Steve Joffe, and Andrea Vandeven to comment on the ethical issues raised by this unusual case. Dr Diekema is immediate past-chair of the American Academy of Pediatrics Committee on Bioethics; Dr Joffe is a pediatric oncologist at Boston Childrens Hospital; and Dr Vandeven is a member of the child-protective-services (CPS) team at Childrens Mercy Hospital in Kansas City, Missouri. K. B. was a 7-week-old girl who was brought to the emergency department for poor weight gain. She was 3 oz over her birth weight. Her parents reported that she had been taking 2 oz of formula every 2 to 3 hours. However, doctors in the emergency department noted that the parents did not know how to feed her and fell asleep while she was crying. CPS was called. They were familiar with the family, because a 17-month-old sister had been previously removed from the home for neglect and placed with a foster family. After an extensive medical workup, K. B. was diagnosed with infantile osteopetrosis. The only treatment for this disease is a bone marrow transplant. Children who do not receive a transplant usually die in the first decade of life. The foster family that had taken the 17-month-old sibling were planning to adopt her but were … Address correspondence to John D. Lantos, MD, Department of Pediatrics, Childrens Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: jlantos{at}cmh.edu