Ann S. Botash

Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review

OBJECTIVES (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions. METHODS Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey. RESULTS The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008). CONCLUSIONS Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse.

From Curriculum to Practice: Implementation of the Child Abuse Curriculum

More than 40 years after the diagnosis of battered child syndrome entered the literature, our pediatric residency programs do not have a significant education requirement for preventing, recognizing, or managing child abuse. Drs. Starling and Boos (2003 [this issue]) succinctly point out that whereas the literature on child abuse is now extensive, child abuse education for physicians has been and continues to be poor. The effect of this inadequate training is immeasurable in terms of missed abuse and subsequent childhood morbidity and mortality. Drs. Starling and Boos (2003) offer a comprehensive core content outline for primary care residency training. This document is a valuable resource for educators, program directors, medical clerkship directors, and fellowship directors. Although this is a major step toward implementation of a curriculum, it cannot stand alone. An agenda for integrating this material into residency programs urgently needs to be developed. In addition, the focus for primary care programs should include a core curriculum for teaching residents appropriate child abuse prevention interventions in the well-child care setting. The Accreditation Council for Graduate Medical Education accredits graduate medical education programs through its Residency Review Committees. The program requirements for pediatric residency education are very broad and generalized and therefore subject to much interpretation in terms of actual content of the curriculum. The Accreditation Council of Graduate Medical Education (2003) is currently implementing a project that will transition the way the Residency Review Committees review programs, focusing on assessing program educational outcomes rather than looking mainly at the structure and process of the program and its potential to educate. With this transition, there is an opportunity to interject requirements to address the “new” 40-yearold morbidity. The next steps for implementing a core curriculum in child abuse should include the following:

Calciferol Deficiency Mimicking Abusive Fractures in Infants: Is There Any Evidence?

T he history of calciferol metabolism and biochemistry is tightly intertwined with that of American pediatrics. Rickets was a widespread affliction of children in urban areas in the 19th and early 20th centuries. Mellanby recognized the anti-rachitic properties of a fat-soluble substance that was incorrectly named ‘‘vitamin’’ D. Shortly thereafter, Eliot undertook a seminal clinical trial in New Haven that demonstrated the ability of cod-liver oil to prevent rickets in infants. Within decades, supplementation of nursing infants became nearly universal, and clinical rickets largely disappeared. In the latter part of the 20th century, lax prescribing of calciferol supplements to nursing children, combined with an increasing number of mothers of darkly pigmented infants choosing to breast feed, led to a resurgence of clinical rickets. Because we are well into the 21st century, clinical rickets in infants again is largely disappearing. As this has happened, there has been an increasing interest in the possibility that degrees of calciferol deficiency insufficient to cause frank rickets could still have deleterious skeletal effects. This interest has been informed by recent information in adults suggesting that levels of calciferol (as assessed by 25hydroxycholecalciferol [25(OH)D]) we have previously considered normal may actually be low. This, in turn, has led to the suggestion that mild degrees of calciferol deficiency, in the absence of actual rickets, could predispose the infant to fractures. It is sometimes argued that such subclinical calciferol deficiency could explain some fractures that have been ascribed to abuse. Multiple longbone fractures have long been recognized as an indicator for child abuse. The implications for the child when fractures caused by abuse aremistakenly attributed to fractures caused by rickets are potentially life-threatening. Similarly, misdiagnosis of abuse in the setting of clinical rickets has significant legal, social, emotional, and clinical implications. In this commentary, we will provide a review of our current understanding of the metabolism of calciferol in infants. We will then discuss recent data defining normal levels of calciferol at various ages, including in infants. We will examine the fracture risk associated with actual clinical rickets and the evidence that this risk is present with milder degrees of calciferol deficiency. Lastly, we will consider the proposition that mild degrees of calciferol deficiency can predispose infants to fractures mimicking those caused by non-accidental trauma of infants.

Being Persistent without Being Pushy: Student Reflections on Vaccine Hesitancy

Our goal as pediatric educators is to graduate physicians who have witnessed effective approaches and have grasped the nuances of communication strategies between vaccine-hesitant families and health care providers. We identified vaccine hesitancy as a recurring topic in 19 of 304 medical student reflective narratives addressing an issue in professionalism or systems-based practice. We conducted content analysis on the narratives in order to gain a better understanding of student perceptions of visits in which they observed a provider discussing vaccine hesitancy with a parent. We identified four major themes: perceived effectiveness of provider-family communication, student reaction to the encounter, physician approach to vaccine hesitancy, and gaps in students’ own knowledge. Most students described communication positively, despite only 4 of 19 observing eventual vaccine acceptance. Information regarding vaccines, vaccine delivery, and approaches to vaccine hesitancy needs to be introduced and enhanced in the educational curriculum of providers at all levels, including medical students, resident physicians, and attending physicians, in order to ensure that providers possess the comprehension and communication skills to ethically optimize vaccine uptake among patients.

United States Medical Licensing Examination and American Board of Pediatrics Certification Examination Results: Does the Residency Program Contribute to Trainee Achievement

Objective To determine whether training site or prior examinee performance on the US Medical Licensing Examination (USMLE) step 1 and step 2 might predict pass rates on the American Board of Pediatrics (ABP) certifying examination. Study design Data from graduates of pediatric residency programs completing the ABP certifying examination between 2009 and 2013 were obtained. For each, results of the initial ABP certifying examination were obtained, as well as results on National Board of Medical Examiners (NBME) step 1 and step 2 examinations. Hierarchical linear modeling was used to nest first‐time ABP results within training programs to isolate program contribution to ABP results while controlling for USMLE step 1 and step 2 scores. Stepwise linear regression was then used to determine which of these examinations was a better predictor of ABP results. Results A total of 1110 graduates of 15 programs had complete testing results and were subject to analysis. Mean ABP scores for these programs ranged from 186.13 to 214.32. The hierarchical linear model suggested that the interaction of step 1 and 2 scores predicted ABP performance (F[1,1007.70] = 6.44, P = .011). By conducting a multilevel model by training program, both USMLE step examinations predicted first‐time ABP results (b = .002, t = 2.54, P = .011). Linear regression analyses indicated that step 2 results were a better predictor of ABP performance than step 1 or a combination of the two USMLE scores. Conclusions Performance on the USMLE examinations, especially step 2, predicts performance on the ABP certifying examination. The contribution of training site to ABP performance was statistically significant, though contributed modestly to the effect compared with prior USMLE scores.

Look before you LEAPP™: An interprofessional approach to bedside pediatric inpatient procedures

Abstract The Golisano Children’s Hospital at Upstate Medical University is a 71 bed children’s hospital within a hospital, serving nearly two million people in Central New York. Minor procedures occur daily in all childrens hospitals, yet team coordination when planning for these procedures is often overlooked. LEAPP™ is a mnemonic for: Listen, Evaluate, Anticipate, Plan, and Proceed. The “Look before You LEAPP™” program was developed by a group of nurses, child life specialists, faculty, a chief resident and a fellow. LEAPP™ is a team-based program providing consistent care to all children undergoing inpatient procedures. It improves patient satisfaction and reduces procedural distress. Through LEAPP™ steps, teams are created at point of care — at the bedside or treatment room of inpatient units. Educational goals are linked to the practical goal of cooperation for good health care. The approach uses an online educational module for residents, students and nurses to introduce an innovative protocol and a planning tool.1 Pocket cards, promotional pens, and logo door-clings, purchased through grant funds (The Foundation for Upstate Medical University) were initially used to encourage participation. Pre/post observations of procedural planning and performance of the nurse, caregiver, physician, child-life specialist and independent observer included patient and family preparation, pain and anxiety, staffing and supplies, and satisfaction. Fifty procedures were assessed pre-implementation and 28 post implementation. Although satisfaction with procedures improved between pre and post LEAPP™ implementation, there were overall differences in satisfaction with procedural management and pain/anxiety control by physicians, caregivers, and staff that remained statistically significant. Interdisciplinary bedside teamwork can be used to support interprofessional education and this education can similarly be used to support improved patient outcomes.

Sudden infant death syndrome, child sexual abuse, and child development.

Since the introduction of the Back to Sleep Campaigns, there has been a dramatic reduction in sudden infant death syndrome in this country. Steven Blatt and Victoria Meguid review the literature surrounding sleep position. Investigators have continued efforts to find other modifiable risk factors of sudden infant death syndrome. A prospective study of more than 33,000 neonates found a link between a prolonged QT electrocardiogram interval and sudden infant death syndrome. Also discussed are investigations seeking to explain the relationship between smoking and sudden infant death syndrome. Ann Botash, Florence Jean-Louis and Mongkae Ploy Siripornsawan review the latest thinking on genital warts and their relation to specific viral etiologies and child sexual abuse. Other symptoms and signs of sexual abuse are the focus of a number of articles that can help the practitioner care for these unfortunate children. Catherine Church reviews medication options for children diagnosed with pervasive developmental disorders or autism spectrum disorders. Finally, in this article, risperidone, fluoxetine and naltrexone are reviewed.

Autism, child abuse, and sudden infant death syndrome

The current literature regarding the standard and nonstandard therapies for children with autism is reviewed. A long term, comprehensive, individualized, multidisciplinary approach remains the best treatment. Physicians caring for the victims of child abuse are frequently asked to render an opinion regarding soft-tissue bruising. A review of the literature suggests that estimation of the age of a bruise should not rely solely on color, but rather should be the result of careful history, a through physical examination, and possibly laboratory testing. The need for a standardized and systematic approach to sudden infant death syndrome is also reviewed. The psychological effects on the parents following sudden infant death is discussed and reveals maternal anxiety and depression and, to a lesser degree, paternal anxiety and depression following the loss of a child. Currently, sleep position continues to be a risk factor for sudden infant death syndrome, although immunizations may not be.

Child abuse, sudden infant death syndrome, and psychosocial development

A review of the literature on child abuse continues to emphasize the importance of careful attention to physical findings. Children who are allegedly sexually abused very often have no abnormal physical findings, yet they may be subjected to repeat examinations in an attempt to document possible physical effects of the abuse. Information is reviewed about the potential psychologic impact of these repeated assessments on young children. Controversy regarding the etiology of sudden infant death syndrome persists, and risk factors are reviewed. Changes in recommendations for infant sleep position by the American Academy of Pediatrics are not universally implemented. The importance of death scene investigations in cases of sudden unexplained infant death is emphasized. A review of the current research on infant colic does not provide many new insights, and the etiology remains controversial. The primary care pediatrician has an important role in providing advice and counseling, albeit on an empiric basis.

Child abuse, sudden infant death syndrome, and attention-deficit hyperactivity disorder

A review of recent literature helps to clarify normal variations in the physical examination of children who are thought to have been sexually abused. In many instances, no abnormal physical findings are discovered. Clinicians must continue to pay careful attention to the history and work with other professionals to implement appropriate management, despite the lack of physical findings. Guidelines for evaluating sudden and unexpected infant deaths are reviewed. The current recommendations of the American Academy of Pediatrics for infant sleep positions are discussed in light of epidemiologic studies in the United States and other countries. Attention-deficit hyperactivity disorder appears to respond best to a combination of stimulant medication, parent training in coping with behavior of affected children, and social skill training for the affected children themselves. A review of recent research failed to reach consistent correlations between resistance to thyroid hormone and attention-deficit hyperactivity disorder.