Howard Fischer

History of In Utero Cocaine Exposure in Language-Delayed Children

To determine whether children with language delays are more likely to have been exposed to cocaine in utero than children with normal language development, a case-control study was undertaken. Based on routine office screening in our primary-care clinic over a 1-year period, we identified 29 consecutive children, aged 24 to 48 months, as language-delayed. They were compared with an approximate 2:1 match of children without language delay who had been seen in the clinic on the same days and who were of similar age. There was more reported cocaine use during pregnancy (six of 29, 21%) among the language-delayed children than among the controls (five of 71, 7%). This difference is statistically significant (P < 0.05, χ2 = 3.92; odds ratio = 3.4 ± 2.2). Discriminant analysis revealed that both cocaine and nicotine exposure were associated with delayed language development — with an unexpected negative, i.e., an antagonistic, protective, interactive effect (F[3,96] = 4.66, R2 = 12.7%, P<.005); neither gender nor caretaker contributed to language development in this sample. These results suggest that children with language delay detected in a clinical setting are more likely to have been exposed in utero to cocaine than children with normal language development. Prenatal cocaine exposure should be a risk factor in monitoring development in children.

Screening for Domestic Violence in a General Pediatric Clinic: Be Prepared!

Objectives. Exposure to violence, particularly domestic violence (DV), negatively affects childrens physical, emotional, and cognitive well-being. The American Academy of Pediatrics recommends routine DV screening of female caretakers of pediatric patients. Few reports of screening in pediatric practices exist, and none have reported outcomes from a resident-run urban academic center. We set out to determine whether the use of the Partner Violence Screen (PVS) increases detection of DV and to test the mechanics of implementing large-scale DV screening in a busy, pediatric residency training clinic. Methods. Using the PVS, we screened a sample of consecutive female caretakers/guardians of children seen for pediatric care in the general pediatric clinic of Childrens Hospital of Michigan from March 1, 2002, through February 28, 2003. Positive screens obtained during the study period were compared with the number of DV referrals received by the clinic social workers from January 1, 2001, through December 31, 2001, before PVS screening began. To test the mechanics of screening, we also analyzed the number of forms returned blank or marked “no opportunity to screen” in the last 8 months of the study period. Results. In the 12 months before use of the PVS, our social work department received 9 referrals because of DV from the general pediatric clinic, among a total of 5446 caretakers/guardians bringing 6380 children for a total of 13 576 patient care visits. In contrast, the social work department received 164 referrals because of positive screening results among 5445 caretakers/guardians bringing 7429 children for 17 346 patient care visits in the 12-month study period after introduction of the PVS. Fourteen of 164 positive PVSs were found to involve nondomestic violence perpetrated by nonpartners or violence with the patient as the victim, not the mother or female caretaker. A total of 150 PVSs involved true DV. The difference in identification of DV with the PVS, compared with the rate before its introduction, was highly significant. The positive predictive value for the PVS was 91.5%, and the identified prevalence rate was 3.7%. In the last 8 months of the study period, 6301 of 8055 PVS forms (78%) were completed; 1754 of 8055 PVS forms (22%) were left blank, but it was not possible to determine whether these represented duplicate screening forms for instances in which the mother or female caretaker had brought >1 child for care. Conclusions. Formal screening for DV with the PVS in this study setting of a busy, urban, academic, general pediatric clinic appeared to be very successful, in terms of increasing referrals and documentation of previously unrecognized DV situations. This increase signals the need for resources (time and/or social work services) to provide appropriate referral services. The PVS identifies nonpartner violence occasionally.

The Natural History of Pityriasis Rosea in Black American Children: How Correct Is the “Classic” Description?

Objectives: To delineate the natural history of pityriasis rosea in black children and to compare our findings with those of the American, European, and African literature on pityriasis rosea. Textbook and journal article descriptions of pityriasis rosea usually offer informationaboutthepresentationandclinicalcourseofthiscondition in white patients. Design: Prospective observational study.

Permanently Damaged: Long-Term Follow-Up of Shaken Babies

Shaken baby syndrome (SBS) is a term denoting a particularly harmful form of child abuse. By definition, 1 these infants have intracranial and retinal hemorrhages in the absence of signs of head trauma or skull fracture. Most SBS victims appear to have significant neurologic damage at the time of diagnosis.2,3 The medical literature, however, does not describe these children as they grow older. A 1986 article4 called for follow-up studies on these children, but a computerized literature search turned up only one paper on long-term follow-up in SBS. Sinal and Ball5 described cranial computerized tomog-raphic (CT) and clinical follow-up in 24 brain-injured children, 17 of whom had SBS. They followed the 15 surviving shaken infants for about 4 years: seven had severe handicaps, and only one was normal.

Immersion Scald Burns and the Ability of Young Children to Climb Into a Bathtub

Introduction. Immersion scald burns in children are often suspicious for neglect or abuse. The history that a child climbed into a tub previously filled with hot water by the parent is common. The childs ability to climb into such a tub is a major factor in determining the reliability of the history. Methods. A standard bathtub was installed in an examination room at a pediatric clinic in a childrens hospital. Foam mats were placed in and outside of the tub. Toy boats were placed in the back of the tub. Children were selected if they were between 10 and 18 months of age, born at term, and had no past or present medical condition that could be expected to have affected their fine or gross motor or central nervous system development and had a normal Denver Developmental Screening Test within the past 3 months. The parent placed the child in a standing position with the child holding onto the front of the tub. Parents encouraged the child to climb into the tub and get the toys. The childs efforts were videotaped. Children were allowed 5 minutes to climb, depending on their attention span and tolerance. Results. Of 176 children in the study, 62 (35%) climbed into the tub. One fourth climbed in head first, and the rest climbed in sideways. Conclusions. Our study may have underestimated childrens climbing abilities because of the absence of a shower curtain to help with balance and the distracting presence of strangers. The diagnosis of abuse is in part based on a described mechanism being inconsistent with the observed pattern of injury. This has severe repercussions for the child and his or her family. Our study brings into question previously held beliefs that these injuries could only be sustained by direct immersion.

“Don’t Call Me ‘Mom’”: How Parents Want to Be Greeted by Their Pediatrician

Background. Physician—patient interaction during the medical interview is essential in establishing the rapport necessary for a successful relationship. Physicians are generally encouraged to shake hands with patients, address patients by name, and identify themselves. Objective. To define parents expectations for greetings by pediatricians and to determine the frequency with which these expectations are met. Design and methods. A total of 100 parents visiting the General Pediatric Clinic at Childrens Hospital of Michigan were recruited. Parents were interviewed at the end of their medical encounter to determine expectations for greeting by their doctor. They were questioned about preferences for shaking hands, the doctors’ use of their names, and the way doctors should introduce themselves. They were then asked if the experience at this visit conformed to these expectations. Results. Overall, 81% of the parents were the childrens mother and 86% were African-American. Over 80% of parents expected physicians to shake hands; 70% of residents and 66% of attendings did. 88% of parents wanted to be addressed by their names; only 14% of residents and 24% of attending physicians did so. All of the parents wanted the physicians to introduce themselves; 84% of residents and 93% of attendings did so. Conclusions. Physicians neither shook hands with many parents who expected it, nor did they address parents by their last names. About 90% of physicians introduced themselves. These disappointingly low results may predispose to parent dissatisfaction. Attending physicians need to teach these small, but important features, and to model them as well.

Prurigo Nodularis in a 9-Year-Old Girl:

A 9-year-old African-American female with a known history of atopic dermatitis presented for evaluation of an intensely pruritic nodular rash on both upper and lower extremities, buttocks, and lower abdomen for more than 1 year. The patient had been treated with several medium-potency topical steroids and antipruritics without appreciable improvement. After considering and excluding other differential diagnoses, the diagnosis of prurigo nodularis (PN) in association with atopic dermatitis was made. Prurigo nodularis usually occurs in middle-aged and older persons and is rarely seen in the pediatric population. The onset of PN in the case presented is considerably earlier than what has been described in literature. The etiology of the disorder is unknown. The management of prurigo nodularis is usually challenging for both patients and treating physicians. Frequently, combinations of several medications or modalities are used in an attempt to control disease activity. Overall, PN is a benign condition in children, particularly when it is associated with atopic dermatitis. It does not increase mortality; however, it can cause significant morbidity in untreated patients.

Nasal Destruction Due to Child Abuse

two thin, nondistressed infants with normal vital signs. Twin A weighed 4.82 kg, twin B 4.80 kg. Only the facial examination produced abnormal findings. Examination of their noses showed (for twin A) a loss of the nasal tip, columella, and distal septum, with collapse of the nares. There was crusted excoriation flanking the philtrum bilaterally (Figure 1). His brother had loss of the right alar rim and collapse of the nostril. Excoriation extended from

Does Pacifier Use in Infancy Decrease the Risk of Obesity

Background. Nonnutritive sucking using a finger or pacifier is a natural reflex for infants. We hypothesized that infants may overfeed if the bottle or breast is constantly offered. Our goal was to determine whether pacifier use in early infancy is associated with lower incidence of obesity at later age. Methods. Parents of 399 infants, 9 to 15 months old, were interviewed and asked whether a pacifier was used consistently for ≥9 months. Body mass indexes at birth, 6 months, and on the day of interview were calculated. Results. In all, 204 (51%) infants used a pacifier, and 195 (49%) were nonusers. More infants in the nonuser group were either overweight—40 (21%)—or obese—32 (16%)—than in the user group—22 (11%) and 22 (11%), respectively (P = .003). Conclusions. Pacifier use in infancy was associated with lower incidence of obesity at 9 to 15 months of age. Offering a pacifier can be protective against infantile obesity.

Giant Congenital Melanocytic Nevi

Giant or large congenital melanocytic nevi (CMNs) measuring more than 20 cm in diameter are present in 1 out of 20 000 newborns, with an estimated 6.3% lifetime risk of developing malignant melanoma. Approximately half of all melanomas that arise within a giant congenital nevus do so by 5 years of age. They occur most commonly on the posterior trunk but may also appear on the head or the extremities. Congenital pigmented nevi have been categorized by size: Giant congenital nevi are more than 20 cm in diameter; small congenital nevi are less than 2 cm in diameter; and intermediate nevi are in between in size. Giant nevi frequently lie in the distribution of a dermatome and will cover areas like an arm, leg, or a significant part of the trunk. These lesions are usually termed in a descriptive manner, for example, coat-sleeve, stocking, bathing-trunk, or giant hairy nevi. Giant hairy nevi are associated with neurological disorders. Nevi on the scalp and neck are associated with an increased incidence of leptomeningeal melanocytosis, epilepsy, and other focal neurological abnormalities. Those located over the vertebral column are associated with increased risk of spina bifida and meningomyelocele. The presence of ‘‘satellite’’ melanocytic nevi increases the risk of leptomeningeal involvement, particularly when located on the head or midline on the trunk. Nevus cells within the leptomeninges may cause increased intracranial pressure with subsequent hydrocephalus, seizures, and motor deficits. We describe a newborn with a bathing-trunk giant congenital pigmented nevus. Case Report