Antoinette L. Laskey

Mechanisms, Clinical Presentations, Injuries, and Outcomes From Inflicted Versus Noninflicted Head Trauma During Infancy: Results of a Prospective, Multicentered, Comparative Study

OBJECTIVE. Our goal was to conduct a prospective, multicentered, comparative study that would objectively verify and explain observed differences in short-term neurodevelopmental outcomes after inflicted versus noninflicted head trauma. METHODS. Children <36 months of age who were hospitalized with acute head trauma confirmed by computed tomography imaging were recruited at multiple sites. Extensive clinical data were captured prospectively, subjects were examined, cranial imaging studies were blindly reviewed, and caregivers underwent scripted interviews. Follow-up neurodevelopmental evaluations were completed 6 months after injury. Head-trauma etiology and mechanisms were categorized by using objective a priori criteria. Thereafter, subject groups with inflicted versus noninflicted etiologies were compared. RESULTS. Fifty-four subjects who met the eligibility criteria were enrolled at 9 sites. Of 52 surviving subjects, 27 underwent follow-up assessment 6 months after injury. Etiology was categorized as noninflicted in 30 subjects, inflicted in 11, and undetermined in 13. Compared with subjects with noninflicted head trauma, subjects with inflicted head trauma (1) more frequently experienced noncontact injury mechanisms, (2) sustained greater injury depth, (3) more frequently manifested acute cardiorespiratory compromise, (4) had lower initial Glasgow Coma Scale scores, (5) experienced more frequent and prolonged impairments of consciousness, (6) more frequently demonstrated bilateral, hypoxic-ischemic brain injury, (7) had lower mental developmental index scores 6 months postinjury, and (8) had lower gross motor quotient scores 6 months postinjury. CONCLUSIONS. Compared with infants with noninflicted head trauma, young victims of inflicted head trauma experience more frequent noncontact injury mechanisms that result in deeper brain injuries, cardiorespiratory compromise, diffuse cerebral hypoxia-ischemia, and worse outcomes.

Utility of hepatic transaminases to recognize abuse in children.

OBJECTIVE: Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. PATIENTS AND METHODS: This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. RESULTS: Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4–4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. CONCLUSIONS: In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.

Prevalence of abusive injuries in siblings and household contacts of physically abused children.

OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old. RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5–18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0–13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8–69.9). CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts.

Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: perhaps "uncommon" is more common than suggested

Objective Recently, it has been suggested that views of the hands, feet, spine, and pelvis should be omitted from routine skeletal surveys (SSs) because these fractures are rarely identified by SS. Our objective was to describe the prevalence of fractures to the hands, feet, spine, or pelvis among SSs obtained for children in a large, multicenter population who underwent consultation for physical abuse. Methods This was a retrospective secondary analysis of data from the Examining Siblings To Recognize Abuse research network, a consortium of 20 US child abuse teams who collected data for all children younger than 10 years who underwent consultation for concerns of physical abuse. This secondary analysis included data only from index children and excluded data from siblings and contacts. Consulting child abuse physicians reported the number of fractures identified and those that were detected by SS. Results Among 2049 initial SSs, 471 (23.0%) showed at least 1 previously unknown fracture including 49 (10.4%) that showed a fracture to the hands, feet, spine, or pelvis. In 10 cases, the SS identified at least 1 fracture of the hands, feet, spine, or pelvis when no other fractures were identified. Conclusions A significant number of occult, abusive fractures would have been missed if SSs had omitted or deferred views of the hands, feet, spine, and pelvis. Given the risks associated with missed abuse, these views should be routinely included in the radiographic SS.

Central hyperventilation related to administration of topiramate

Topiramate is a recently released antiepileptic agent used in the treatment of patients with refractory seizure disorders. In addition to its antiepileptogenic activities, it results in inhibition of carbonic anhydrase isoenzymes II and IV, which are present in the central nervous system. A 15-year-old female who presented with hyperpnea and primary respiratory alkalosis is reported. Other possible etiologies of the central hyperventilation syndrome were excluded. The problem resolved within 24 hours after discontinuing topiramate.

Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma.

Abstract Subconjunctival hemorrhages in infants and children can be a finding after nonaccidental trauma. We describe 14 children with subconjunctival hemorrhages on physical examination, who were subsequently diagnosed by a child protection team with physical abuse. Although infrequent, subconjunctival hemorrhage may be related to abuse. Nonaccidental trauma should be on the differential diagnosis of subconjunctival hemorrhage in children, and consultation with a child abuse pediatrics specialist should be considered.

Postmortem skeletal survey practice in pediatric forensic autopsies: a national survey.

Abstract:  Recommendations for the evaluation of an unexplained death in infancy include a postmortem skeletal survey (PMSS) to exclude skeletal trauma. Objectives of this study were to assess adherence to these recommendations in forensic autopsies in children equal to or less than 36 months of age, and what factors influence the use or nonuse of the PMSS. We surveyed pathologists who were members of the American Academy of Forensic Sciences. The survey included practice characteristics about where, when, and how PMSS were done. Nearly all respondents (99.6%) indicated they performed PMSS at least some of the time; however, almost a third did not use PMSS for all suspected Sudden Infant Death Syndrome (SIDS), abuse, unsafe sleep, or undetermined causes of death. Despite evidence that “babygrams” are inappropriate in a SIDS workup, 30% of pathologists use them preferentially. Despite SIDS being a diagnosis of exclusion that requires a PMSS, almost 10% of pathologists do not order a PMSS. Future research is necessary to reduce barriers to this important component of the pediatric forensic autopsy.

Anesthetic implications of the grey platelet syndrome

Purpose: To describe the obstetrical anesthetic care provided to two sisters with a rare qualitative platelet disorder, the grey platelet syndrome (GPS).Clinical features: Both patients manifested thrombocytopenia prior to delivery without previous history of a bleeding diathesis or other abnormal laboratory tests of coagulation function. The first required emergency Cesarean section due to fetal bradycardia. Due to the thrombocytopenia and the emergency nature of the procedure, general anesthesia was used. During the C-section, 1.5–2 litres of old blood was noted in the abdominal cavity which was attributed to an old splenic capsular tear of unknown etiology. Work-up for the thrombocytopenia revealed large platelets on the peripheral smear with abnormal aggregation on platelet function studies. Electron microscopy of the platelets revealed absent alpha granules, diagnostic of GPS. The second patient, the sister of patient #1, presented in a similar fashion. However, at presentation, the platelet count was 112,000·m−3 and spinal anesthesia was provided without complication for Cesarean delivery. The same patient presented for a second delivery during which fetal bradycardia necessitated emergency C-section under general anesthesia. Despite administration of six units of platelets, blood loss was 5,200 mL. Her postpartum course was uncomplicated and she and the infant were discharged home on postoperative day #4.Conclusion: The primary concerns for the anesthesiologist looking after patients with qualitative platelet defects are related to defective coagulation which influences the need for perioperative replacement of blood products and limits the use of regional anesthesia.RésuméObjectif: Décrire les soins anesthésiques obstétricaux prodigués à deux sœurs atteintes d’un dérèglement plaquettaire rare, le syndrome des plaquettes grises (SPG).Éléments cliniques: Les deux patientes présentaient une thrombocytopénie avant l’accouchement, sans antécédent de diathèse hémorragique ou d’autres anomalies de la fonction de coagulation. La première a subi une césarienne d’urgence à cause de la bradycardie fœtale. Étant donné la thrombocytopénie et l’urgence de l’intervention, on a réalisé une anesthésie générale. Pendant la césarienne, 1,5–2 litres de sang vieilli ont été notés dans la cavité abdominale et attribués à une ancienne rupture de la rate d’origine inconnue. L’examen de la thrombocytopénie a révélé de grandes plaquettes à la périphérie des prélèvements et une agrégation anormale lors de l’étude de la fonction plaquettaire. Les plaquettes examinées au microscope électronique montraient une absence de granules alpha, ce qui a amené le diagnostic de SPG. La seconde patiente, sœur de la première, présentait les mêmes signes. Cependant, au moment de l’accouchement, la numération plaquettaire était de 112,000·m−3 et la rachianesthésie pour une césarienne a été réalisée sans complication. Cette même patiente a connu un second accouchement pendant lequel la bradycardie fœtale a nécessité une césarienne d’urgence sous anesthésie générale. Malgré l’administration de six unités de plaquettes, la perte sanguine a été de 5 200 mL. La récupération du postpartum a été sans complications et la patiente et son enfant ont pu quitter l’hôpital au quatrième jour.Conclusion: Dans des cas d’anomalie plaquettaire qualitative, l’anesthésiologiste est surtout préoccupé par les défauts de coagulation qui influencent les besoins de remplacement périopératoire par des produits sanguins et limitent l’utilisation de l’anesthésie régionale.

Predictors of Screening and Injury in Contacts of Physically Abused Children

OBJECTIVE To determine rates of screening in contacts of children evaluated for physical abuse, and the relationship of clinical characteristics to screening recommendation and completion and injury identification. STUDY DESIGN This is a planned secondary analysis of a prospective study of 1918 contacts of 1196 children referred for subspecialty abuse consultation in 20 US centers. We used multivariable logistic models to determine the relationship of index child characteristics, contact child characteristics, and shared characteristics to screening and injury identification. RESULTS We identified injuries or disclosures of abuse in 180 (9.4%) contacts. Recommended screening was omitted in >20% of subjects for each screening modality. At least 1 screening test was more likely to be completed in contacts of index children of non-White race or Hispanic ethnicity (OR 1.45, 95% CI 1.13-1.87), with abuse-specific injuries (OR 2.15, 95% CI 1.63-2.83), with a confession (OR 2.18, 95% CI 1.17-4.07), when the history changed (OR 1.65, 95% CI 1.05-2.61), when an occult injury was found by imaging in the index child (OR 1.84, 95% CI 1.39-2.43), and when families lacked private insurance (OR 1.63, 95% CI 1.15-2.31). CONCLUSION Completion of screening recommended for contacts of potentially abused children is relatively poor, despite high risk of injury. Several clinical and demographic factors were associated with increased contact screening.

Research priorities for a multi-center child abuse pediatrics network − CAPNET

Although child maltreatment medical research has benefited from several multi-center studies, the new specialty of child abuse pediatrics has not had a sustainable network capable of pursuing multiple, prospective, clinically-oriented studies. The Child Abuse Pediatrics Network (CAPNET) is a new multi-center research network dedicated to child maltreatment medical research. In order to establish a relevant, practical research agenda, we conducted a modified Delphi process to determine the topic areas with highest priority for such a network. Research questions were solicited from members of the Ray E. Helfer Society and study authors and were sorted into topic areas. These topic areas were rated for priority using iterative rounds of ratings and in-person meetings. The topics rated with the highest priority were missed diagnosis and selected/indicated prevention. This agenda can be used to target future multi-center child maltreatment medical research.