Kenneth W. Feldman

Abusive Head Trauma During a Time of Increased Unemployment: A Multicenter Analysis

OBJECTIVE: To evaluate the rate of abusive head trauma (AHT) in 3 regions of the United States before and during an economic recession and assess whether there is a relationship between the rate of AHT and county-level unemployment rates. METHODS: Clinical data were collected for AHT cases diagnosed in children younger than 5 years from January 1, 2004 until June 30, 2009, by hospital-based child protection teams within 3 geographic regions. The recession was defined as December 1, 2007 through June 30, 2009. Quarterly unemployment rates were collected for every county in which an AHT case occurred. RESULTS: During the 5½-year study period, a total of 422 children were diagnosed with AHT in a 74-county region. The overall rate of AHT increased from 8.9 in 100 000 (95% confidence interval [CI]: 7.8–10.0) before the recession to 14.7 in 100 000 (95% CI: 12.5–16.9) during the recession (P < .001). There was no difference in the clinical characteristics of subjects in the prerecession versus recession period. There was no relationship between the rate of AHT and county-level unemployment rates. CONCLUSIONS: The rate of AHT increased significantly in 3 distinct geographic regions during the 19 months of an economic recession compared with the 47 months before the recession. This finding is consistent with our understanding of the effect of stress on violence. Given the high morbidity and mortality rates for children with AHT, these results are concerning and suggest that prevention efforts might need to be increased significantly during times of economic hardship.

Use of Supplemental Vitamin D Among Infants Breastfed for Prolonged Periods

OBJECTIVES: To determine the rate of vitamin D supplementation in predominantly breastfed children. To identify patient characteristics, parental beliefs, and practitioner policies associated with supplementation. METHODS: A prospective observational study was conducted in a practice-based research network. Network pediatricians completed a survey regarding their policy on vitamin D supplementation for breastfed infants. Parents of children 6 to 24 months old completed a survey on the initial type of feeding given to the child, length of breastfeeding, formula supplementation, and use of multivitamins. Parents indicated their level of agreement with statements regarding vitamin D supplementation. RESULTS: Among 44 responding pediatricians, 36.4% indicated that they recommended vitamin D supplementation for all breastfed infants. A total of 2364 surveys were completed on age-eligible children; 1140 infants were breastfed for at least 6 months with little or no formula supplementation. The rate of vitamin D use for these infants was 15.9%. Use of vitamin D was significantly associated with parental agreement that their childs pediatrician recommended supplementation (odds ratio [OR]: 7.8), and that vitamins are unnecessary because breast milk has all needed nutrition (OR: 0.12). Among parents of predominantly breastfed infants who indicated that their childs doctor recommended vitamin D, 44.6% gave the supplementation to their child. Conversely, 67% of parents agreed that breast milk has all needed nutrition, and only 3% of these parents gave vitamin D to their children. CONCLUSIONS: A minority of breastfed infants received vitamin D supplementation. Educational efforts directed at both physicians and parents are needed to increase compliance with vitamin D supplementation guidelines.

Position Paper: Definitional Issues in Munchausen by Proxy

In 1996, a multidisciplinary task force of experts was created to develop working definitions for the constellation of behaviors currently described as Munchausen by proxy (MBP). The aim of the task force was to develop a synthesis of the most current thinking in pediatrics, psychiatry, psychology, child protection, and law and to articulate the current consensus among professionals to facilitate the identification and treatment of this complex clinical problem. The term Munchausen by proxy was first used by Roy Meadow (1977), a British pediatrician, to describe illness-producing behavior reminiscent of adult Munchausen syndrome but using the child as a proxy. Adult Munchausen syndrome, described in 1951 by Asher, is a psychiatric disorder in which an adult intentionally induces or feigns symptoms of physical or psychiatric illness to assume the sick role. MBP was initially described as “the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care for the purpose of indirectly assuming the sick role” (American Psychiatric Association, 1994, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV], p. 475). The fact that Munchausen syndrome and MBP share the same name has resulted in considerable confusion. Although once thought to be quite rare, most experts now believe that MBP is fairly common. Using the results of a careful but conservative British study (McClure, Davis, Meadow, & Sibert, 1996), we estimate that a minimum of 600 new cases of just two forms of MBP (suffocation and nonaccidental poisoning) will present in the United States each year. Given the wide spectrum of pediatric conditions that have been known to be feigned, the problem is far from trivial. Furthermore, experts now agree that MBP

Cervical spine MRI in abused infants.

OBJECTIVE To determine clinical utility of screening with cervical spine MRI to detect unsuspected cord injury in children with head injury from child abuse. DESIGN Prospectively collected case series. Setting-Tertiary care childrens hospital and county medical examiners office. PATIENTS Twelve children with intracranial injury secondary to child abuse. None was clinically suspected to have cord injury. Includes all eligible children whose attending felt: (a) needed follow-up cranial imaging: (b) could be safely imaged; and (c) whose caretakers consented between November, 1991 and September, 1994. INTERVENTIONS MRI scans of the cervical spine were obtained either more than 3 days after clinical presentation or postmortem. MAIN OUTCOME MEASURES Clinical observations by neurologist, child protection team pediatrician and medicinal examiners by prospective protocol. MRI scans evaluated by prospective radiology protocol with emphasis on cervical cord injury. RESULTS Four of the five autopsied children had small subdural or subarachnoid hemorrhages at the level of the cervical spine; MRI scan did not identify them. MRI did not identify cord injury in any child studied. CONCLUSION Routine cervical spine MRI scans are probably not warranted in children with head injury secondary to child abuse without clinical symptoms of cervical cord injury.

Risk Factors for Mortality in Children with Abusive Head Trauma

OBJECTIVE We sought to identify risk factors for mortality in a large clinical cohort of children with abusive head trauma. STUDY DESIGN Bivariate analysis and multivariable logistic regression models identified demographic, physical examination, and radiologic findings associated with in-hospital mortality of children with abusive head trauma at 4 pediatric centers. An initial Glasgow Coma Scale (GCS) ≤ 8 defined severe abusive head trauma. Data are shown as OR (95% CI). RESULTS Analysis included 386 children with abusive head trauma. Multivariable analysis showed children with initial GCS either 3 or 4-5 had increased mortality vs children with GCS 12-15 (OR = 57.8; 95% CI, 12.1-277.6 and OR = 15.6; 95% CI, 2.6-95.1, respectively, P < .001). Additionally, retinal hemorrhage (RH), intraparenchymal hemorrhage, and cerebral edema were independently associated with mortality. In the subgroup with severe abusive head trauma and RH (n = 117), cerebral edema and initial GCS of 3 or 4-5 were independently associated with mortality. Chronic subdural hematoma was independently associated with survival. CONCLUSIONS Low initial GCS score, RH, intraparenchymal hemorrhage, and cerebral edema are independently associated with mortality in abusive head trauma. Knowledge of these risk factors may enable researchers and clinicians to improve the care of these vulnerable children.

Cervical spinal cord injury in abused children

Five infants and toddlers who sustained cervical spinal cord injury as the result of child abuse are described. Three cases are previously unreported. Diagnosis was complicated by coexistent brain injuries and their treatments, subtle and/or evolving paralysis, and central cord syndrome, in which arm function is diminished but leg function is preserved. Definitive spinal imaging by magnetic resonance imaging (MRI), computed tomography, and plain radiographs was delayed because of life support efforts. When completed, the MRI was most sensitive to cord injury. Evidence of associated bony spinal injury was often absent or unapparent until healing occurred; 4 children had spinal cord injury without (or with minimal) radiological abnormality. The 3 children presenting to our hospital with cord injury represent 1% of the estimated cases of inflicted head injury seen during a 23-year period.

The central venous catheter as a source of medical chaos in Munchausen syndrome by proxy

PURPOSE The aim of this study was to determine what percentage of childhood central venous catheters (CVC) are placed in victims of Munchausen syndrome by proxy (MSBP) and to evaluate the clinical indications and complications of CVCs in MSBP. METHODS Study design was by retrospective chart review. Data were obtained from the regional childrens hospital and regional child abuse consultation network. Patients in the MSBP series were all children who on consultation were determined to be victims of MSBP, from 1974 through 1996. Patients in the central catheter series were all children who had central venous catheters placed 1991 through 1995, excluding children whose catheters were placed for cancer chemotherapy or for chronic renal failure. Consultation records of MSBP cases were abstracted noting the clinical characteristics of victims and perpetrators. Hospital procedure codes were reviewed for children who had CVCs placed. Those who had discharge diagnostic codes that commonly require CVC placement were not reviewed, but charts of children with diagnoses not usually requiring CVCs were evaluated. Descriptive statistics and chi2 and Fishers Exact test were used for comparisons. RESULTS Sixteen of ninety-three (17%) of MSBP victims had central lines, including two deaths caused by assault through the lines. Line sepsis occurred in 9 of 16 (56%) patients. Primary reasons for CVC were for administration of medicines that can normally be administered orally or subcutaneously (7) or for severe nutritional depletion (8). All but one of the children had symptoms of multiple organ system involvement. Siblings had frequently been victimized. The mean age of symptom onset was 19 months, yet the mean age at diagnosis was delayed until 82 months. All perpetrators were the mother. Fathers were usually physically or emotionally unavailable. Nearly one third of mothers had prior medical training and one third had themselves been victims of prior physical or sexual abuse. Ten of fifteen mothers previously exhibited Munchausen behavior themselves. Of children at our institution who had central venous catheter placement, 8 of 709 (1.1%) were MSBP victims. CONCLUSIONS CVCs are frequently placed in MSBP victims for physiological problems, malnutrition, or failure to respond to normal treatments. Surgeons should consider requesting systematic evaluation for MSBP in patients seeking CVC placement for diagnoses not usually requiring CVCs lest they become unintentional collaborators in abuse of these children.

Additional Injuries in Young Infants with Concern for Abuse and Apparently Isolated Bruises

OBJECTIVE To determine the prevalence of additional injuries or bleeding disorders in a large population of young infants evaluated for abuse because of apparently isolated bruising. STUDY DESIGN This was a prospectively planned secondary analysis of an observational study of children<10 years (120 months) of age evaluated for possible physical abuse by 20 US child abuse teams. This analysis included infants<6 months of age with apparently isolated bruising who underwent diagnostic testing for additional injuries or bleeding disorders. RESULTS Among 2890 children, 33.9% (980/2890) were <6 months old, and 25.9% (254/980) of these had bruises identified. Within this group, 57.5% (146/254) had apparently isolated bruises at presentation. Skeletal surveys identified new injury in 23.3% (34/146), neuroimaging identified new injury in 27.4% (40/146), and abdominal injury was identified in 2.7% (4/146). Overall, 50% (73/146) had at least one additional serious injury. Although testing for bleeding disorders was performed in 70.5% (103/146), no bleeding disorders were identified. Ultimately, 50% (73/146) had a high perceived likelihood of abuse. CONCLUSIONS Infants younger than 6 months of age with bruising prompting subspecialty consultation for abuse have a high risk of additional serious injuries. Routine medical evaluation for young infants with bruises and concern for physical abuse should include physical examination, skeletal survey, neuroimaging, and abdominal injury screening.

Child abuse in infants with proximal physeal injuries of the femur

Objective: Child abuse has been recognized to be a common cause of femur fractures in infants. Fractures of the proximal femoral physis in abused infants have been less emphasized. Our report seeks to highlight this infrequent but clinically important inflicted injury. Methods: Report of 2 cases and a literature review of fractures of the proximal femoral physis in infants, including the role of abuse in this injury. Conclusion: Proximal femoral physeal injuries occur infrequently in infants but often result from abuse. Diagnosis may be difficult due to lack of femoral head ossification before 4 months of age and clinical findings suggesting developmental dysplasia of the hip. Current imaging modalities can differentiate physeal injuries from developmental dysplasia of the hip. Early recognition and treatment can minimize sequelae.

When is childhood drowning neglect

Concern that drowning is frequently considered neglectful and referred to Childrens Protective Services (CPS) led us to review the frequency and associations of referral. Records of 95 childhood drowning and near drowning victims hospitalized between 1981 and 1987 were reviewed. Reactions of 14 nurses, 27 physicians, and 13 social workers to 4 case scenarios were solicited. Only 8 drownings were reported to CPS. Reporting was significantly more likely if the child was younger or nonwhite, the family poor, the injury in the bathtub, social work involved, a prior CPS report recognized or consideration of neglect documented in the chart. Reporting was not related to the childs sex or clinical outcome, the parents marital status or drug/alcohol history, type of child supervision, or time until discovery or history of prior accidents. Only 28% of the cases had social service evaluation. Intensive care staff were least likely and emergency room staff most likely to consider drowning scenarios neglectful. Profession, age, sex, years in practice and whether one was a parent did not affect the referral decision. Judgment that scenarios were neglectful correlated closely with the decision to report. Lapse in supervision by an intoxicated father, was thought most neglectful. Judgment was split whether poor families letting infants bathe alone or with siblings were neglectful or the result of poor knowledge of hazard and infant development. A 4-year-old who wandered into a lake at a picnic was felt a victim of an unfortunate accident. Clinicians found decisions about referral stressful.(ABSTRACT TRUNCATED AT 250 WORDS)